New Patient Form
Please print form, fill it out, and bring to your first appointment.
2112-A Danville Road
Decatur, AL firstname.lastname@example.org
Phone: (256) 353-8696
Fax: (256) 353-7388
Monday & Wednesday
12:00 PM - 7:00 PM
Tuesday, Thursday, & Friday
7:30 AM - 2:30 PM
We currently accept most private insurance plans, which means that we work with hundreds of companies. Although we maintain computerized histories of payment by a given company, they do change. Therefore, it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to- date information we have, but it is only an estimate.
We base the patient portion of your bill on our most current date, but there are several factors that can affect this estimate. For example, there may be a deductible, or you may have received treatment in another office prior to joining our office. Insurance companies do not inform us of any charges to your benefits. We do, however, investigate your benefits as thoroughly as possible.
We bill your insurance as a courtesy. Dental insurance is a contract between the employer and the patient. It has no connection at all to us as your dental office. The extent of coverage varies greatly from company to company, sometimes even within a company. It has absolutely nothing to do with the level of service provided by us, and the fee charge for these services.
An often-misunderstood term used by many insurance companies is "UCR". This is an arbitrary fee ceiling at which the insurance company will stop reimbursement. These fee ceilings were often set 10-15 years ago. After this ceiling, coverage for a particular procedure may cease, meaning the patient will have an extra portion that is due. Despite our best efforts at giving you an accurate estimate, a patient will occasionally owe the amount of the difference. Again, this has nothing to do with the fee charged but the level of coverage negotiated by the insurance company.