Insurance Agreement

Ross H. Fishman, DMD
Board Certified Pediatric Dentistry
Practice Limited to Children and Teens

To the Parents of our Patients,

Please read the following information. It will be necessary for you to sign this statement before we agree to accept assignment of payment from your insurance company. We desire to avoid any misunderstanding as a result of the increasingly complicated process of arranging payments.

Please be aware that many insurance companies are undergoing significant changes that complicate reimbursement and produce difficulties for you and your health care providers. Should repeated insurance submissions be required, there may be additional administrative charges to your account.

Filing your insurance is a time-consuming task. It is a courtesy service performed by this office which we hope to be able to continue to offer you.

Should you have any questions, please feel free to speak with our office staff.

OFFICE INSURANCE POLICY AGREEMENT

Current Dental Insurance Company:*

Policy Holder's Name:*

First Last

Employer

Policy Holder's DOB:*

This is the date of birth of the policy holder.

Network

In Network
Out of Network

Please indicate your understanding of the following:

1*

I understand that it is my responsibility to provide Fishman Pediatric Dentistry with the correct insurance information.*

2*

I understand that often insurance plans change on a yearly basis and that it is my responsibility to alert Fishman Pediatric Dentistry of any changes regarding my insurance.*

3*

I understand that I am responsible for any balance on my account as a result of my insurance company's failure to make a payment on an insurance claim.*

I understand and agree that I am personally responsible for the payment of all examination and treatment fees on my account. If my insurance company fails to make prompt payment, or denies payment for any reason, I will be responsible to make payment for the full amount without delay.

I understand and agree that I am responsible for the estimated amount not paid by my insurance company. This portion, plus the deductible, is due at the time of the appointment, when examination or treatment is rendered. I understand that after my insurance company makes payment, there may still be a balance remaining, for which I am responsible.

I have been informed if I hold a PPO insurance, I am responsible for amounts due after insurance pays. I am aware my insurance may be OUT OF NETWORK, resulting in my out of pocket being my responsibility. The staff has informed me OUT OF NETWORK policies and procedures.

Child's Name*

First Last

Child's Name

First Last

Child's Name

First Last

Child's Name

First Last

Parent signature*

Date*