Patient Registration

Patient Information

Primary Dental Insurance Information

Secondary Dental Insurance Information (If Applicable)

DENTAL INSURANCE IS A CONTRACT BETWEEN THE POLICY HOLDER AND THE INSURANCE COMPANY. AS A COURTESY TO YOU WE WILL SUBMIT INSURANCE CLAIMS ON YOUR BEHALF AND WE WILL ASSIST YOU IN THE COLLECTION OF LEGITIMATE CLAIMS. IN THE EVENT YOUR INSURANCE COMPANY IS SLOW TO PAY OR DISALLOWS THE CLAIM PAYMENT, THE AMOUNT OWED IS THE PATIENT’S RESPONSIBILITY. ALL BALANCES ON ACCOUNTS OVER 30 DAYS PAST DUE WILL BE SUBJECT TO A FINANCE CHARGE OF 1.5% PER MONTH. A FEE OF $50 MAY BE ASSESSED FOR APPOINTMENTS CANCELLED WITH LESS THAN A 48 HOURS NOTICE.

Powered by ChronoForms - ChronoEngine.com

Resources