I UNDERSTAND THAT PAYMENT FOR DENTAL SERVICES PROVIDED BY THIS OFFICE FOR EITHER ME OR MY DEPENDENT IS MY RESPONSIBILITY AND DUE AT THE TIME SERVICES ARE RENDERED.
I UNDERSTAND THAT ALL DENTAL SERVICES PROVIDED ARE CHARGED DIRECTLY TO ME AND THAT I AM PERSONALLY RESPONSIBLE FOR THE ENTIRE COST OF TREATMENT. AS A COURTESY, THIS OFFICE WILL ASSIST ME WITH PREPARING MY INSURANCE FORMS AND WILL MAKE EVERY EFFORT IN OBTAINING REIMBURSEMENT FROM MY INSURANCE COMPANY. I UNDERSTAND ANY DEDUCTIBLE AND ESTIMATED CO-PAYMENTS ARE DUE IN FULL AT THE TIME OF SERVICE.
I give my consent to West Valley Periodontics to receive payment directly from my insurance company, but understand that this office cannot render services based on the assumption that insurance company will pay. I agree to notify the office immediately if there are any changes regarding my dental benefits.
I hereby authorize West Valley Periodontics to release any of information that may be required by my dental benefits company, third party and/or healthcare provider.
I have read and understand the above conditions regarding my dental benefits.