Form Consent For Use And Disclosure Of Health Information Page 2

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Newburyport Dental Team AND YOUR INSURANCE PLAN - HOW THEY WORK TOGETHER
The staff at Newburyport Dental Team is pleased that you have insurance benefits to help with the cost of your
dental care. We would like to help you obtain the maximum use of these benefits. With this in mind, please read
the following information regarding our insurance claims processing policies so that we can work together to best
utilize your benefits.
DO YOU ACCEPT MY INSURANCE?/HOW MUCH WILL THEY PAY?
We currently accept all private care insurance plans (plans that do not require you to select a dentist from a list or
require our office to accept a reduced fee for services). This means that we work with literally thousands of
companies. Although we can maintain computerized history of payment by a given company, they do change, and
therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based
on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like to know your
exact insurance benefit, we will be happy to file a “pre-treatment authorization” with your insurance company
prior to treatment. This does delay treatment but will give you the exact out of pocket figure you may require.
I THOUGHT I PAID MY PORTION BUT I GOT A BILL, WHY?
We base the patient portion of your bill on our most current data although there are many factors that can affect
this estimate. There may be a deductible (individual or family) or you may have received treatment in another
office prior to joining Newburyport Dental Team, which is not calculated into our database. Sometimes you may
need to see a specialist for care, which also uses your annual benefit. Insurance companies do not (and cannot in
most cases) notify us of changes to your benefits, they only notify you. If these situations apply to you, please let
us know when we estimate your treatment plan so we may adjust accordingly. Also, information given by
insurance representatives over the phone is not a guarantee of payment or guaranteed to be accurate. Since it is
your insurance plan it is also your responsibility to be familiar with all aspects of your individual plan.
INSURANCE DIDN’T PAY, NOW WHAT?
We bill your insurance as a courtesy. If insurance does not pay within 90 days, Newburyport Dental Team
reserves the right to request payment in full from you for services performed and let you collect the insurance
funds that are due to you. This is rare but it is important that you recognize that the insurance policy you carry is a
legal contract between you and your insurance company. Our office is not, and cannot be a part of that legal
contract. Ultimately, you are responsible for all charges incurred in our office.
FINANCIAL OPTIONS
Newburyport Dental Team does request payment in full for your portion at the time of service. Beside ATM
Debit Cards (which are run like a credit card-no pin needed), we also accept MasterCard, VISA, American
Express and Discover. If you are in need of an extended finance option, we also work with Care Credit and
Springstone, who offer low monthly payments with possible low fixed interest rates for those who are eligible.
These plans and their benefits are designed to help meet your treatment plan needs. Just ask one of the patient
service staff for an application.
We welcome you to our family and look forward to helping you get the healthy, beautiful smile you’ve always
wanted. If there is anything we can do to make your visits here more pleasant, please don’t hesitate to ask one of
our staff members.
I have read, understand, and accept the terms of the above outlined policies for insurance handling and
financial commitments that I may incur as a result of treatment at Newburyport Dental Team.
________________________________________
_____________________
Signature
Date

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