We are committed to providing you with the highest quality dental care. The following is a statement of Champlin Family Dental Office/Financial Policies. We ask that you please read, agree to, and sign before any treatment is rendered.
IF YOU HAVE INSURANCE
Our goal is to maximize your Insurance benefits. It is important to understand that Dental insurance is a contract between you, the insured, and your insurance company. Dental Insurance was not designed to pay for all dental care. The treatment recommended by Champlin Family Dental Doctors is never based on what your insurance company will pay. Due to pending claims and patient privacy issues, we do not always know how much an insurance company has already paid to another office or specialist, and the balance remaining on a yearly maximum.
Please be prepared to show your insurance card and driver's license at the time of your visit. It is the patient's responsibility to understand the extent and limits of your coverage and to provide our staff with accurate information so as a curtsey to you, we can process your claim efficiently (i.e. insurance company address, phone number, etc.). It is not our place to enter into disputes between you and your insurance company regarding deductibles, copayments, coverage, etc, Other than to provide factual information. We do not directly participate in every Insurance program. At the time of treatment, the patient/guarantor is responsible for the estimated portion the insurance does not cover or the down payment arrangements discussed at the time of presenting your treatment plan. If for some unforeseen reason your insurance carrier has denied or not made payment within 60 days, the patient guarantor is responsible for the balance in full. Certain conditions may require your authorization for release of X-rays and or narratives for assignment of benefits. Your signature below authorizes us to offer this when it applies to your situation. If we do not participate with your insurance, 100% of the total cost is requested at the time of service, Our staff will help you process whatever paperwork is required. However, the ultimate responsibility lies with you for payment of any and all monies due.
RELEASE AND ASSIGNMENT OF BENEFITS
I hereby authorize Champlin Family Dental to release to my benefits program or its representatives any information including the diagnosis and the records of any treatment or examination rendered to me. I authorize, if applicable, payment to be sent to Champlin Family Dental.