PATIENT RESPONSIBILITY
PERTINENCE
REFERRAL
REGISTRATION FORMS
REQUESTING SOCIAL SECURITY NUMBER
CANCELLATION POLICY
TARDINESS
PAYMENT POLICY
INDEPENDENT FINANCING
PREPAYMENT REQUIREMENT FOR DENTAL LAB WORK
DENTAL INSURANCE
INSURANCE PAYS SUBSCRIBER
EMERGENCY APPOINTMENT
INITIAL APPOINTMENT (NON-EMERGENCY)
TREATMENT PLAN
APPOINTMENT ORDER
APPOINTMENT CONFIRMATION
SCHEDULE CHANGES
APPOINTMENTS FOR FAMILIES
REFUSAL OF TREATMENT
RECORD TRANSFER REQUEST
QUESTIONS
DISCLAIMER
HIPAA NOTICE OF PRIVACY PRACTICES

DENTAL INSURANCE

All patient fees are the responsibility of the responsible party.

Insurance forms are submitted as a courtesy.

Dr Pepin and this office are out-of-network for all insurance. Insurance is a contract between the insurance carrier, you, and /or your employer. The patient is responsible for ensuring this office has the correct insurance information prior to each appointment. Insurance claims are submitted as a courtesy. ONE claim each primary/secondary/tertiary will be submitted per date of service. If incorrect/incomplete insurance information is provided, a fee will be added for the additional time/effort/cost to correctly resubmit the claim(s).

This office is not responsible for knowing your insurance coverage. This includes, but is not limited to, not exceeding the maximum, knowing which treatment(s) are covered/not covered, frequency restriction, age restriction, and co-payment amounts.

Dental treatment will be provided regardless of coverage limitation(s).

If you have any questions regarding your coverage, please contact your insurance carrier.

The primary insured, the employee/subscriber, will need to sign a form, prior to or at the initial appointment, for each covered patient, to authorize claim submission. The authorization will need to be renewed each year.

Bring your insurance card to each visit.

Notify us of any future changes in your insurance coverage.