1740 Euclid Ave., Bristol, VA 24201
1990 Hwy 394, Blountville, TN 37617
Our office is pleased to accept your insurance assignment. We offer this service as a courtesy to our patients. However, it must be clearly understood 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. Following is a statement of our policy governing insurance claims. The patient will pay the co-payment (the amount estimated as not covered by the insurance company) at the time services are rendered. After we receive payment from your insurance company, any difference will be billed to you. We expect payment within 10 days after receipt of your statement.
IF YOU UNDERSTAND AND AGREE TO THE ABOVE OFFICE POLICIES PLEASE SIGN YOUR NAME BELOW AND WE WILL ACCEPT YOUR INSURANCE ASSIGNMENT.
To reduce our administrative costs and keep our fees to you as low as possible, we ask that you pay your co-payment at the time you receive treatment.
Please indicate below the method of payment you intend to use to pay for your dental treatment, including your co-payment.
Please check below letting us know that you have read and agree to the above office polices.