IF YOU HAVE DENTAL INSURANCE, PLEASE READ THE FOLLOWING INFORMATION:
Responsibility for payment: It is the patient’s ultimate responsibility for knowing your insurance benefits and for payment to our office.
In-Network or Out-of-Network: You may ask our receptionist if we are in-network with your insurance company. Plans vary and coverage often depends on if you see an in-network or out-of-network provider, so it is your responsibility to know your insurance plan.
Submitting insurance claims: We will gladly submit your dental claim to your insurance company on your behalf.
At your first appointment: Each insurance company and each plan’s benefits are different. Until we receive the Explanation of Benefits from your insurance company, we do not know the amount covered by insurance. We ask all patients to make a down payment at the first appointment accordingly:
- Non-surgical root canal procedures- 25% of treatment fees
- Surgical procedures – 50% of treatment fees
- Two insurances- Normally $0 unless you know your maximum benefits have been used or procedure(s) will otherwise not be covered. Please let us know if this is the case.
- If an estimate or pre-determination of benefits was obtained, we will collect the estimated patient portion. Remember, we can only provide an estimate of the out of pocket expense to the patient based on information provided to us by the carrier on the day of inquiry. Circumstances may change between that day and the day the claim is processed by the carrier after treatment is completed.
Pre-determination of Benefits: If you need to know the amount that insurance is expected to pay, we will submit for a pre-determination of benefits upon your request. However, pre-determination is NOT a guarantee of payment from your insurance company and can vary significantly from the actual payment. Please note that it typically takes approximately four weeks for most insurance companies to respond to these requests.
Blue Cross-Blue Shield Federal Employee Program & Blue Cross-Blue Shield of Wyoming: These plans will not pay our office directly or send an Explanation of Benefits to us. As a result, we require payment in full at the time of service. We will promptly submit your claim on your behalf and your insurance company will pay you directly. If you have secondary insurance and would like us to submit the claim to them, you must provide us with a copy of your Explanation of Benefits from your primary insurance.
Secondary Insurance: If you have coverage by two insurance carriers, we will submit a claim to both your primary and secondary. Generally, we will not require a down payment; however, at your first appointment, you will be asked to leave a form of payment on file with us for any balance not covered by insurance.
After we receive payment from your insurance: It typically takes up to 12 weeks for you insurance to pay our office. After an insurance payment is received, you balance is determined.
- If a balance is due: WE WILL SEND YOU WRITTEN NOTIFICATION OF ANY REMAINING BALANCE AND THE DATE ON WHICH THE BALANCE WILL BE CHARGED TO THE FORM OF PAYMENT YOU LEFT ON FILE. (See below)
- If a refund is due: This credit will be issued promptly to you.
Option for keeping a form of payment in file: At the first appointment, all patients are asked to leave a credit/debit card on file for payment of any remaining balance not covered by insurance. All account numbers are stored through a secure on-line banking system, and charges cannot exceed the amount you authorize. If you are not comfortable leaving your account information with us, you may elect to pay in full at the time of service. For your convenience, we accept cash, check, VISA, Master Card, Discover, American Express and Care Credit*.
IF YOU DO NOT HAVE DENTAL INSURANCE, PLEASE READ THE FOLLOWING INFORMATION:
Payment of fees: Payment is due at the time of service. For your convenience, we accept cash, check, VISA, Master Card, Discover, American Express and Care Credit* are accepted.
*Care Credit: Care Credit is a flexible patient program specifically designed for healthcare expenses, Care Credit lets you complete your procedure immediately and then pay for it over time with monthly payments. Our office will pay the interest for you the first six months; you are charged no interest if you pay the balance within the specified time (typically six months). In addition, Care Credit is a revolving credit line that you may use for other medical, dental or veterinary expenses with no need to reapply. Please speak with our receptionist before treatment if you are interested in applying for this service.
Fee Schedule: Fees for endodontic services vary; they are dependent on the complexity of the root canal system within the tooth. Included in the cost of treatment fees are all periapical x-rays, follow-up appointments, and a one-year check-up.
IF YOU WOULD LIKE OUR OFFICE TO SUBMIT A CLAIM TO YOUR DENTAL INSURANCE, PLEASE SELECT ONE OF THE FOLLOWING:
_______I (Or Guarantor*) authorize this office to charge my credit/debit card or checking account that I left on file for any balance after my insurance pays. I understand that Dr. Dico Hassid and Associates will notify me in advance of any balance due prior to posting this balance to my payment file. Please notify me by:
_____________ U.S. Postal Service
_______I (Or Guarantor*) will pay my fee in full at the time of service with cash, check, VISA, Master Card, Discover, American Express or Care Credit*. If my insurance company pays the office directly, I understand that I will be issued a refund accordingly.
*If someone other than non-minor patient is assuming financial responsibility for payment of this treatment, a Financial Responsibility Agreement must be completed.
PLEASE SIGN AND DATE:
Patient (or Guardian if patient is a minor)
Acknowledge of Receipt of Notice of Privacy Practices: I received a copy of Dr. Hassid and Associates’ Notice of Privacy Practices. NOTE: You may refuse to sign this acknowledgement.
Patient (or Guardian if patient is a minor)