ASSIGNMENT OF BENEFITS/ FINANCIAL AGREEMENT
Chico Dental Care (CDC) is committed to providing you with the most comprehensive dental care, using
only the highest quality materials and technology available. We are also committed to having a clear
understanding with our patients regarding exam findings, recommended treatment options, financial
arrangements and all questions that may arise so that you may fully comprehend and participate in
maintaining optimum oral health.
All charges you incur are your responsibility regardless of your benefit plan (insurance)
coverage. We must emphasize that as your dental care provider, our relationship is with you - our
patient - not with your benefit plan. Your dental benefit plan is an agreement between you and your
benefit plan company. Our practice is not a party to that agreement. If payment from your benefit plan is
not received within 60 days from the date of service, you will be expected to pay the balance in full.
Your co-payment and estimated out-of-pocket portion is due at the time treatment is provided.
Your estimated out-of-pocket portion may be adjusted after the date of treatment, depending
upon the final reconciliation of payments by your benefit plan. CDC IS NOT LIABLE for any cost
not covered by your benefit plan or responsible for researching all the benefits, limitations, etc.,
of your benefit plan. All quotes generated by CDC regarding insurance coverage are estimates only.
We generate these estimates based on the most current coverage information provided to us by our
patients and their benefit plans. We urge you to review your current benefit policy booklet, so that you
are aware of limitations or exemptions, such as frequency limits, waiting periods and restrictions. We
encourage you to preauthorize claims prior to scheduling treatment; preauthorization, however, is not a
guarantee of coverage. You (patient) are responsible for informing us of any dental benefits you have
used outside our office (even if you were referred from our office) prior to scheduling treatment with us,
as this will affect the accuracy of your treatment estimate.
As a courtesy to you, we will submit and process all insurance claims on your behalf. You may direct
your benefit plan to pay your benefits directly to our practice by signing the authorization on this
Assignment of Benefits Agreement. In order for our practice to submit your claim, you must bring a
dental benefit plan card or proof of dental benefits and provide benefit plan changes/updates as they
occur. Our practice accepts cash, personal checks, MasterCard, Visa, and Discover. In some cases, third-
party or extended payment financing (such as Care Credit®) for dental treatment may be available upon
request and approval.
We request 48 hours notice for cancellation of appointments. We will charge a rescheduling fee
of $50 per hygiene (cleaning) appointment and/or $75 per hour of scheduled dental treatment
for cancellations less than 48 hours in advance, late arrival for scheduled appointments (more
than 10 mins.), and missed appointments. Subsequent appointment failures will be assessed a
fee of $70 per hygiene and/or $100 per hour of scheduled treatment. We will assess a processing
fee for returned checks. Patients with multiple failures may be subject to dismissal from the
practice.
I HAVE READ AND ACCEPT THE TERMS AND CONDITIONS OF THIS ASSIGNMENT OF BENEFITS
AGREEMENT.> I HEREBY ASSIGN TO CHICO DENTAL CARE ALL MY RIGHT, TITLE, AND INTEREST IN AND TO
ANY AND ALL DENTAL BENEFITS OTHERWISE PAYABLE TO ME FOR ORAL HEALTH TREATMENT RENDERED
BY CHICO DENTAL CARE. I AUTHORIZE THE USE OF THIS SIGNATURE ON ALL INSURANCE SUBMISSIONS. TO
THE EXTENT PERMITTED BY LAW, I CONSENT TO THE USE AND DISCLOSURE OF MY PROTECTED HEALTH
INFORMATION TO CARRY OUT PAYMENT ACTIVITIES IN CONNECTION WITH MY CLAIMS.