Financial Agreement and Assignment of Benefits Please complete this Financial Agreement and Assignment of Benefits form below. If you have any questions call us on (615) 915-6090. Patient name:(* required) First Last Patient date of birth:(* required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Financial Agreement and Assignment of BenefitsThis agreement is to inform you of your financial obligation for your dental service. Our office will accept an assignment of benefits from your insurance company with the provisions listed below. The following provisions identify our policies governing insurance claims and payment: We will use our best efforts to complete insurance information forms and submit a claim on your behalf. Our office will not enter into a dispute with your insurance company over any claim. We will provide necessary documentation your insurance company requests. We will cooperate fully with the regulations and requests of your insurance company. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company. We require you to pay the estimated co-payment, which is the amount not covered by your insurance company, at the time we provide service to you. The co-payment is only an estimate of charges and may be found to be insufficient after review by your insurance company. Our office accepts cash, MasterCard, Visa, Discover and American Express. In addition, we offer outside financing through Care Credit. Insurance payments ordinarily are received within 30-60 days from the time of billing. If your insurance company has not made payment to our office within 60 days from the time of billing, we will ask you to pay the remaining balance at that time. You will be responsible for seeking reimbursement from your insurance company. Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. We perform routine insurance billing procedures upon verification of coverage. However, if your claim is denied, you will be responsible for paying the full amount at that time. If you are unable to keep your account current, we may be unable to provide additional dental services except for where services are prepaid. In case of default, you agree to pay collection costs and reasonable attorney fees. Please do not hesitate to ask if you have any questions regarding this financial agreement. We are committed to providing you with the most positive experience in dental care. SubmitName of Legal Guardian or Authorized Representative:(* required) If not applicable use 'self'Today's date:(* required) MM slash DD slash YYYY Do you wish to receive a copy of this Financial Agreement and Assignment of Benefits?(* required) Yes No E-mail address:(* required) Please sign(* required)Important: You consent to sign this document electronically.
