New Patient Forms

New Patient Forms: Insurance
Information Disclaimer

It is very important for any dental patient to have some understanding of how dental insurance works. Your employer contracts with an insurance company, the insurance company creates a custom tailored policy based on what your company is willing to pay as a premium. This policy is unique to your company although it may share some similarities to other policies. The insurance company has the ability, based on the legal document “policy”, to pay or not pay any claim at any time or to exclude certain procedures etc to limit their exposure. Their legal relationship is with you the patient and not the dental office which is a third party provider.

The information is very limited as to what they tell us. When we call on your benefits we receive some information relevant to the patient being registered in the insurance program and usually a few lines of percentage of coverage’s. We receive no information on specifics of your policy. What we do get on all of the information they send to us is in bold letters that states “Notice: Provider acknowledges and understands that the information contained herein reflects current files. Claims will be processed according to benefit and membership information on file at the time of processing. Therefore, the information contained herein does not guarantee reimbursement.”

Please understand as a patient at our office we do everything possible to ensure that you get your maximum benefit from the insurance. When the insurance company processes a claim is anybody’s guess. It can be upwards of 6 months for them to process although that is an exception and not the rule. At the end of the day the insurance company holds all the cards, they can refuse or deny anything they choose. That is why it is important that you understand that when you receive a treatment plan from our office that it is an estimate only. We cannot possibly know all the ins and outs of the thousands of insurance policies out there.

It’s important for you to have a copy of your policy and some understanding of it. This document is our attempt to avoid any financial misunderstandings. In the end you are responsible for anything your insurance company doesn’t cover for any reason. Our goal as an office is to give you the best treatment possible and meet or exceed your expectations. We devote a great many hours discussing how we might make it a better experience for you the patient. Thank you for your continued business and confidence you have with our office.  By signing this document I have read and understand the above information.

Your electronic signature and date serve as proof that you have seen and thoroughly read Campbell Dental Group's Insurance Information Disclaimer on

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