Our Office is pleased to accept your insurance assignment as soon as the responsible party verifies your exact coverage. We will file your claim forms and assist you in every way we can. However, it must be fully understood that the contract is between you and your insurance company and you are fully responsible for any amount not paid by your insurance.
Office policy regarding insurance assignment:
___ 1. Since by taking your insurance on assignment we have to wait for payment, this courtesy may be withdrawn if circumstances warrant it. The patient co-payment will be due at the time when services are rendered.
___ 2. If you discontinue care without the Doctor’s authorization, the balance of your account is due and payable in full immediately, even if your insurance has been filed. (If the insurance does pay; it will be refunded if you have a zero balance.)
___ 3. Your insurance should pay within 30 days. If your insurance has not paid within 60 days, you must pay the balance due and be reimbursed by your insurance company when and if it pays.
___ 4. We mail statements every month so if there is a balance that is of concern feel free to call us first to verify if insurance is still pending.
___ 5. In restorative treatment your yearly deductible and percentage co-payment is due a time service is rendered. This figure is an approximate amount configured with what insurance information we have on file. After insurance pays on all claims, if a balance is still due a statement will be mailed.
___ 6. You are required to sign an “Assignment To Pay” form and any other assignment documents required by your insurance company if applicable.
___ 7. Our office DOES NOT GUARANTEE that your insurance will pay. We will make every attempt, at the time of service, to receive verification of your policy benefits.However, if for some reason, your insurance claim is denied, you are responsible for the full amount of your bill.
___ 8. Our office WILL NOT enter into a dispute with your insurance company over your claim. THIS IS YOUR RESPONSIBILTY AND OBLIGATION.
___ 9. Our office does not file secondary insurance claims. We will be happy to provide you with the appropriate claim form to file with insurance reimbursement to be directed to the patient. However, the balance due after primary insurance payment has been made is due at the time of billing or time of service.
___ 10. The Patient Manager must sign all special arrangements regarding finances and Patient with approval from the Doctor.