Dental Insurance Information
Thank you for choosing our office for your child's dental care. All information in this form is confidential and transmitted over a secure, encrypted connection.
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Please check the boxes if you agree to the statements below.
Our Practice is considered an OUT OF NETWORK provider. Your insurance will still provide benefits, but will pay at what is a usual, customary, or reasonable rate. What this means to you is that co-pays are generally higher than if you decided to see a NETWORK provider.
You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay. We file all insurance electronically, so your insurance company will receive each claim within days of the treatment. You are responsible for any amount that insurance does not cover.
Our Practice can file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment. We at no time guarantee what your insurance will or will not pay on each claim. Once again, we file claims as a courtesy to you.
*** For a further explanation of dental insurance in our office, please visit our website at PlunkSmiles.com ***
I have read and understand the above information and will be given a copy of so desired.
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