We accept all major dental insurance payments; however, we may not be an “in-network” provider for your plan. Any insurance plans may be subject to a co-pay. As a courtesy to our patients, we will submit insurance claims to any dental insurance company but we are only “in network” with Delta Dental Premier and Cigna. Some Cigna plans are still considered out of network.
Insurance estimates are not a guarantee of payment. Many insurance companies exclude certain dental procedures or downgrade procedures to a lesser reimbursement level. We do our best to get the latest and most accurate coverage information for our patients but we cannot guarantee coverage, even with formal “pre-estimates.” You are responsible for all charges not paid by your insurance.
Your Patient Records are your property. It should be noted that Patients agree to abide by our Radiograph Policies when joining, or transferring from, our Dental Practice. This specifically includes accepting the responsibility for making full payment (with special payment arrangement if needed) for the value of said X-rays/Radiography in place before being released.
For EXISTING PATIENTS who wish to transfer their Records and/or Radiography*, associated fees will be assessed prior to transfer. Additionally, said patient must indicate on a release form, in writing, that they wish their records to be released, and to whom. While we do our best to streamline these processes, please be aware that it may be necessary to come in physically to “release” your records and/or collect them ~ dependent on circumstances ~ and by signing below you agree to do so if requested. [Please see our RADIOGRAPH POLICY for further specifics, which is available online and/or upon request].
To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status of if my
medication changes, I shall inform the dentist and staff at the next appointment without fail.
I hereby authorize payment directly to Amherst Village Dental of the dental benefits otherwise payable to me. I hereby authorize Amherst Village Dental to release any information concerning my health or dental care, advice, treatment or supplies provided. This information is to be used in administering dental claims and/or discussing treatment options with other dental professionals. I understand that any estimates given to me are not a guarantee of coverage or payment by my insurance coverage.
I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered.