As a courtesy, Hiremath Orthodontics will file a claim for your orthodontic insurance benefits. The amount estimated to be paid by your insurance company will be placed on an insurance ledger. When a payment is received, it will be credited to the insurance ledger. (Patient payments will be credited to your patient ledger.) Payments will be made according to the insurance company’s policies. Many insurance companies pay a placement fee, followed by monthly or quarterly payments over the estimated length of treatment. Most insurance companies do not pay the entire benefit in a lump sum at the beginning of treatment.

This contract is the total allowable fee provided by your insurance company. The contracted amount may reflect a managed care/insurance discount.

My signature authorizes this office to file my claim(s) and assigns to this office all rights, title, and interest to my orthodontic reimbursement benefits under the patient's insurance policy. I understand that my signature also allows this office to release information regarding my visits to the patient's insurance carrier. If regular orthodontic appointments are not kept by the patient, we cannot continue to accept payment from the insurance company. The insurance company will be notified that the patient is “inactive” and the insurance payments will be stopped.

I understand that I am responsible for any portion of the total estimated insurance benefit that is not paid by my insurance carrier.

If my insurance does not cover orthodontic benefits or is cancelled/deleted for any reason, I understand that I am responsible for the entire case fee.

If there are changes to my orthodontic insurance benefits, I will notify Hiremath Orthodontics.

If Hiremath Orthodontics receives an Explanation of Benefits (EOB) from my insurance carrier notifying them that my benefits have been terminated, I understand that any amount remaining on the insurance ledger will be moved to the patient ledger and become my responsibility.

DUAL INSURANCE If a patient is covered by two orthodontic insurance plans, Hiremath Orthodontics will file claims for both policies. We can expect the primary carrier to pay the estimated benefit. It is our experience, however, that the amount which will be paid by the secondary insurance cannot be accurately estimated. Most secondary benefit plans do not pay the entire lifetime benefit.

Because we cannot accurately estimate the amount that will be paid by the secondary carrier, no money is placed on the secondary insurance ledger. When a payment is received from the secondary insurance, it will be credited to the responsible party's overall contract balance, thereby reducing the number of payments. Payments by the responsible party are due monthly regardless of payment received by the secondary insurance.


Hiremath Orthodontics

Dr. Kumar Hiremath
We.will give you a reason to smile


Hiremath Orthodontics

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