Financial Responsibilities Acknowledgement 2020
Financial Responsibilities Acknowledgement
As a courtesy to you. Rite Smile Dental does their best to try to contact Your insurance ahead of any procedure so that we can let You detail and an a approximate cost Howeever I recognize this is only a courtesy and I acknowledge the follow;,
- I acknowledge that it is my responsibility to know whether or not insurance is currently active. It is not RiteSmile Denial's responsibility to check this and if services performed at RiteSmile Dental are not covered as a result of my plan being inactive, I am responsible for any costs incurred.
- I acknowledge that it is m responsibility to provide up-to-date insurance information should my plan change. If a service is not covered because I failed to provide up-to-date insurance information, it is RiteSmile Dental's right to charge me for these services and then reimburse me once payment has been received by the new insurance
- I acknowledge that it is possible that some services performed at Rite Smile Dental may end up not being covered by my insurance; as some policies do not cover certain services/procedures, or may have frequency limitations as to how many times in a Calendar Year a certain service may be. performed (such As exams, sealants, Slings, etc.). As a courtesy, Rite Smile Dental will do their best to keep track of certain frequency Urdu (within our office; Rite Smile Dental does not obtain history from previous dentists), but I understand that it is ultimately my responsibility to know my plan's limitations and that I will be responsible for payment in full for any services which are not covered. If a service is not covered and I would like to dispute it, it vim be my responsibility to contact my insurance to do so.
- I acknowledge that it is my responsibility to know what my deductible and co-insurance percentages are and which services are and are not covered. I am also aware that some services, such is fillings and =owns, may have additional costs to upgrade to composite (white) or porcelain on top of my co-insurance
- I acknowledge that, although Rite Smile Dental will do their best to keep track of my remaining maximum (within our office; Rite Smile Dental does not factor in payments made by your insurance to other providers), it is ultimately my. responsibility to know how much remaining max i have. I am responsible for payment in full for any costs incurred as a result of my plan maximum having been exhausted
- I acknowledge that it is my responsibility to know if my plan has any waiting periods for any services. If a service is not covered because a waiting period is in place, I am responsible for the cost in fu
- I acknowledge that it is my responsibility to know whether my plan has a Missing Tooth Clause for Major services including dentures, bridges and implants. I am responsible for the cost in fall if a service is not coveted due to a Missing Tooth Clause being in place, or if there is no Missing Tooth Clause but my insurance only covers the least costly replacemes.at option in lieu of the service I received (i.e. a denture instead of an implant or bridge).
- I acknowledge that any information provided by my insurance company through a pre-determination of benefits, though in general accurate, is NOT A GUARANTEE of my 00P cost or that the service will be covered Additionally, any trestle= plan costs which are provided to me by Rite Smile Dental are estimates and are NOT A GUARANTEE of costs
- I acknowledge that Rite SmiliDeatal will submit claims on my behalf and that they are diligent in addressing any issues which arise in the prom. However, if the claim is not paid within 120 days of my visit, or after three unsuccessful attempts by Rite Smile Dental, I will become responsible for payment in full for all services. I can then attempt to submit the claim on my own behalf and have payment sent to me from my insurance company (or Rite Smile Dental will reimburse me if payment is sent to than).
- I acknowledge that tarn respoyible for payment in full of any invoices received. I understand that if I feel there are any discrepancies on my bill, it is nu responsibility to review the EOB's which I receive from my insurance company, and then contact my insurance company regarding any disputes I may have regarding what the EOB states is owed
- I am aware that there is a 2% late fee each time a payment is not received by the due date listed on the invoice. Any outstanding bill which I do not pay within eight months of the first invoice bag sent out will be sent to collections. If my account is sent to collections, I am aware that I will be responsible for any collection costs incurred from the collection company (LC. System).