Signature will be recorded later.
NoFirst Name:Birthdate:3rd Party Payer (Insurance) AgreementLast Name:YesDate: 11/30/2023All charges that you incur at our office are your personal responsibility to pay. You may pay for your charges in full at each visit (and pursue your own reimbursement if desired) or choose to use our 3rd party payer filing service (dental insurance filing service). If you chose to use our filing service, we will process your and/or your dependant’s dental insurance claims on your behalf with your dental insurance company (3rd party payer). Your 3rd party payer benefits will be verified before or soon after your first visit but ultimately you are responsible for understanding the terms of your dental insurance policy. You will be required to pay any unmet deductible and subsequently, any co-payment or co-insurance amounts per your 3rd party payer policy. We request that you pay your co-payment and/or your coinsurance amounts each visit. All amounts that you pay to South Bound Brook Dental are considered deposits against your outstanding balance. No refunds will be made as long as you have an unpaid balance on your account. Refunds will only be made when you have a credit balance. This normally occurs after your treatment has been completed and all payments from your 3rd party payer have been received. You must agree not to file any dental insurance claims directly and you must inform us immediately of any change in your insurance coverage. Your 3rd party payer must allow you to have reimbursement payments sent directly to our office. If your 3rd party payer does not allow this we require that you pay for all treatment at the time that treatment is rendered.We will notify you of any charges that your 3rd party payer declines to pay and ask that you make payments to our office in a timely manner. We will bill your 3rd party payer at the appropriate time and use our best efforts to obtain payment. However, any charges that remain unpaid 60 days after billing become your personal responsibility to pay. I hereby accept full financial responsibility for charges incurred for services rendered at this office. I authorize the office of South Bound Brook Dental to affix my name to any and all claims or documents as related to any and all dental health benefits due to me and my dependents. I authorize the release of any dental/medical or other information necessary to process a claim requesting payment be made to the provider of service. I hereby authorize payment of dental benefits otherwise payable to be irrevocably assigned to the provider of service. I understand that services are rendered and charged to the patient and not to the 3rd party payer. I acknowledge that this office cannot accept responsibility for collecting an unpaid 3rd party claim or negotiating a disputed settlement. I also agree that this obligation shall exist regardless of private contractual agreement between myself and any 3rd party payer, attorney, or other 3rd party not signing this agreement.