Assignment of Benefits Form

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Dental benefits claim form
Dental benefits claim form

Assignment of Benefits Form

Martin Taylor Dentistry office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.

  • Although we are willing to complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement. By having our office process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment.
  • We ask you to sign this form and/or any other necessary assignment documents that may be required by your insurance company. This instructs your insurance company to make payment directly to our office.
  • We ask you to pay the copayment, which is the amount not covered by your insurance company, at the time we provide service to you.
  • Insurance payments ordinarily are received within 30-60 days from the time of billing. If your insurance company has not made a payment to our office within 60 days, we will ask you to pay the balance due at that time. You will be responsible for seeking reimbursement from your insurance company at that time.
  • We perform routine insurance billing procedures upon verification of coverage. Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. If your claim is denied, you will be responsible for paying the full amount at that time.
  • We perform routine insurance billing procedures upon verification of coverage. Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. If your claim is denied, you will be responsible for paying the full amount at that time.
  • We will cooperate fully with the regulations and requests of your insurance company. Our office will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that may arise. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.

I HAVE READ AND UNDERSTAND THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THE DOCTOR.

Print Name_____________________________________________Date________________

Signature of Patient/Responsible Party___________________________________________

Download Assignment of Benefits Form

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Martin Taylor Dentistry

4.8 Based on 81 reviews
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Dr. Taylor, Dr. Martin, and their entire staff are the very best. The front desk staff, the dental assistants, and dental hygienists are excellent. I’ve been to many dentists over the years, and they are the most skilled and professional group of people that I have encountered. You can be confident you will be fully informed about what is recommended for a treatment plan and what it will cost. I’ve had the gamut of dental procedures — crowns, implants, root canals, and more routine care. It’s been made as pleasant and comfortable as possible by their skill, as well as their kindness and understanding. I wholeheartedly recommend Martin and Taylor Dentistry.

Alice L.

Alice L. 4 months ago

I have been a patient of Dr. Taylor’s for most of my adult hood. I have had everything done from a filling to multiple dental implants. All of my procedures have been straightforward with zero complications and as little discomfort as possible. Even after my implants I had minimal pain! Before I saw Dr. Taylor I was terrified of dentists, but he put me at ease with his expertise. The hygienists are kind, thorough but gentle, and knowledgeable. The office staff is very friendly and helpful. The office itself is modern and impeccably clean. I highly recommend Martin Tayler dentistry and won’t trust my teeth to any other dentists.

Rosemary B.

Rosemary B. 3 months ago