Facts Regarding Insurance Assignment

Our office is pleased to accept your insurance assignment. FOR NEW PATIENTS WE DO ASK THAT YOU PAY FOR SERVICES IN FULL AT YOUR FIRST VISIT.  By bringing in a completed claim form, insurance ID card and/or policy booklet.  We can assist you in getting reimbursement for your first visit charges and approximate future co-payments.  We offer this service as a courtesy to patients.  It must be clearly understood, however, that the “contract” is between the patient and the insurance company, the account thereby being the responsibility of the patient for any amount not paid by the insurance company.

  • Your insurance is a policy that you or your employer has purchased from an insurance company.  Every policy is different and our experience is that the vast majority will cover a percentage of your dental fees.  We are a third party in this arrangement.
  • Many plans state that procedures are covered “at 50%, 80% or 100%”.  Be aware that the benefits of your plan pays is based on the insurance companies usual and customary fees.  The benefits your plan pays is largely determined by how much your employer/union paid for the plan.
  • Insurance companies established “Usual and Customary” fee schedules may or may not have an accurate relationship to what usual and customary fees actually are for a given area.  It has been our experience that some insurance companies tell their insured “fees are above that usual and customary fees” – rather than saying to them that “our benefits are low.”  This may be so because there are various ways and calculations by which the company established their usual and customary fees.  Therefore, it is possible that different insurance companies will have different allowable fees for the same geographical area.  The dentist’s fees may be within one company’s but not within another company’s “usual and customary” range.  Remember, you only get back what your employer/union puts in, less the profits of the insurance company.
  • We require our patients to sign this “Authorization to Pay The Doctor” form (or any other necessary assignment documents required by your insurance company).  By doing so, the insurance company will make payment directly to our office. The patient will pay the co-payment (the amount not covered by the insurance company) as agreed upon during the financial consultation.  For those patients with “dual” insurance, we will file the secondary insurance after receiving payment from the primary insurance.
  • Our office does NOT guarantee that the patient’s insurance company will pay. We will perform our routine insurance billing procedures upon verification of coverage.  If for some reason, however, the patient’s insurance claim is denied, the patient is then considered to be responsible for the full amount of the bill.

IF YOU UNDERSTAND AND AGREE WITH ALL OF THE ABOVE, PLEASE FILL OUT THE FORM BELOW AND WE WILL ACCEPT YOUR INSURANCE ASSIGNMENT.

I authorize Dr. Jessup to submit claims for payment to my insurance carrier on my behalf and assign to such providers benefits payable.  I authorize release of any information necessary to review, investigate or evaluate any claims for benefits.