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7 Northern Virginia Dental Associates, PC INSURANCE INFORMATION SHEET Subscriber Name (employee w/insurance): Subscriber Address: Subscriber s Home # ( ) Work #: ( ) Subscriber s SSN: Subscriber s Date of Birth: Employer: Employer s Address: Insurance Company: Mailing Address: Phone # for verification: ( ) Insurance ID# (if not SSN) Group # Patients Covered by this Plan: Name Date of Birth I agree to pay an estimated copayment at time of service as requested. I understand that all fees are my responsibility and that any amount not paid by my insurance company within 45 days (in excess of estimated copayment) will be paid promptly by me upon receipt of a billing statement. I permit any information necessary to process insurance claims for the above-referenced patients to be released to the insurance company and their consultants. Signature: Name: Date:

8 Northern Virginia Dental Associates Insurance Policy We are thrilled that you have dental insurance coverage to help offset your cost of dental care. As you know, insurance has become more and more complicated in recent years i.e. the pediatric dental benefit on medical coverage; deductibles on preventive services; more exclusions and down-graded procedures, etc. With this in mind, we have established this policy to help avoid any miscommunications. Your insurance is an agreement between you, your employer and your insurance company. We, as a third-party, do not have a copy of your plan, nor can we access it in full. Verification varies with each insurance company s software integration and generally does not include exclusions. For this reason, we will provide an estimate of your copayment, however it is strictly an estimate. We will not call your insurance company at the time of your appointment. If you have questions about coverage, your inquiry must be made PRIOR to the time you are scheduled to be treated, and we encourage patients to make this call so that they better understand their plan. No insurance covers all dental procedures. We recommend the highest level of care care that we would chose for our own families. Many plans provide a least cost alternative to the best care. If you wish to discuss options as they relate to your coverage, we request that you initiate this conversation at least 2 business days prior to your appointment and have a copy of your plan documents with you. Our staff is not responsible for obtaining that information. Again, this type of discussion should occur PRIOR to your appointment, NOT AT your appointment. We retain the right to charge for our time if scheduled treatment is cancelled at the time of the appointment due to insurance questions. Providing a dental estimate is more difficult than a medical estimate due to fine details such as age restrictions, down-grading and other type of exclusions things that are not common in medical insurance. For this reason, your estimate is an estimate. We will either issue a refund or send a statement once a claim is paid, which will reflect any difference from the estimate. Dual insurance will still carry a copayment according to the percentage of coverage on each plan. Benefits are coordinated, not processed separately. We will collect estimated copays at time of service. Any difference once both insurances have paid will be either billed or refunded. Additional Important Items A Deposit may be required to schedule lengthy appointments. This deposit will be applied to your copay for that visit or will be forfeited if the appointment is broken or cancelled within 24 business hours. All broken appointments and cancellations within 24 business hours are subject to a minimum charge of $50 for your reserved time. MANY plans now have deductibles and/or copays for preventive and diagnostic service. If so, you will receive a statement following your cleaning visit. Please remit your payment promptly. I have read and understand the policy of this office as described above. Signature: Date: