Patient Responsibility

We are pleased to assist you with your dental insurance.  If you have dental insurance, please be aware that insurance quotes are an ESTIMATE only.  Coverage may be different if your deductible has not been met, annual maximum has been met, or if you coverage table if lower that average.


I understand that I am responsible to pay all co-payment at the time of service, prior to leaving.


If my insurance determines that I have not met my deductible, I understand that I will be fully responsible for payment in a timely manner, no more that 30 days after I have been notified by insurance and/or provider.


I acknowledge that I assume full financial responsibility for services rendered to me, if my insurance carrier denies or does not cover my claim for these services.  I understand the terms of this form and accept financial responsibility with or without insurance coverage.