• 6 State Road • Danvers, MA 01923 • t: 978.774.6855 • f: 978.774.1734
  • 41 Vine Street • Manchester, MA 01944 • t: 978.526.7864
  • www.orthonorthshore.com

OFFICE POLICY REGARDING INSURANCE BENEFITS


Patients who are eligible for orthodontic benefits, are responsible for providing updated insurance information.

The business office will assist with the completion of claims as a courtesy to patients. However, verification of benefits is never a guarantee. Therefore, the insured are encouraged to know and confirm their benefits.

Insurance companies may request proof of continuation of treatment. Within the estimated treatment time, the insured can provide a canceled check or cash receipt along with his or her signature. This is generally adequate for most insurance companies.

As a courtesy, the financial office is accepting payments from all insurance companies who agree to pay the provider.



PAYMENTS TO OUR OFFICE: We require patients to make financial arrangements directly with us for the payment of the orthodontic services to be rendered. Should the insurance company not agree to pay the provider, the insurance company should reimburse the insured. If benefits are stopped for any reason, the patient is responsible for the balance.

FLEXIBLE SPENDING PLANS/CAFETERIA PLANS


Your financial obligation is to this office directly, on the designed payment schedule regardless of your pre-tax benefit coverage.

I have read and understand the above policy regarding insurance benefits for orthodontic treatment.

Patient/Parent Signature