 In order for us to maximize your dental benefits on a yearly basis please do the following:
PLEASE have your insurance card ready so we can copy it for our records.
PLEASE
submit a completed "Pinedale Dental Patient Questionnaire" form for
each family member with signatures releasing information and assignment
of benefits. We will then complete an insurance form here in our office
and submit it to your insurance company electronically.
If
insurance does not cover or pay the total charge of services rendered,
the patient or responsible party will be responsible for ALL UNPAID
EXPENSES AT THE TIME OF SERVICE.
BLUE CROSS - BLUE SHIELD
PATIENTS: Blue Cross-Blue Shield sends payment to the patient
(subscriber). We require all Blue Cross patients pay the balance due at
time of service or bring in the Blue Cross check when you receive it
and sign it over to us.
YOUR
INSURANCE CONTRACT is between you and the insurance company and it is
YOUR responsibility to know YOUR insurance policy coverage.
Any balance due over 60 days will be subject to a 1.5% monthly or (18% annual) finance charge.
THERE WILL BE A $30.00 CHARGE ON ALL RETURNED CHECKS
YOU WILL BE RESPONSIBLE (IF NECESSARY) FOR ALL COLLECTION AND/OR COURT COSTS AND ATTORNEY FEES |
