Pettigrew Dentistry Financial Insurance Form

Pettigrew Financial and Insurance Information

Patient First Name	Invalid Input
Patient Middle Name	Invalid Input
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*What person is responsible for this account?	Invalid Input
* Insured's Name:	Invalid Input
* Insured's Address:	Invalid Input
* Insurance Company:	Invalid Input
* Insurance Company Phone:	Invalid Input
* Mailing Address:	Invalid Input
*Group Policy #:	Invalid Input
Secondary Insurance Company:	Invalid Input
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Our office is pleased to accept your insurance assignment. We offer this as a courtesy to our patients. However it must be understood that the contract is between you and your insurance company. You are responsible for any amount that your insurance does not cover. The following are our policies regarding insurance claims.

You must provide all insurance information forms filled out and signed
the estimated percentage of your bill as treatment is rendered
Your insurance should pay in 30-60 days. If your insurance has not paid within 90 days we may request that you pay the balance due and you be reimbursed by your insurance company

ANY unpaid balance in excess of 90 days may be subject to collection. If this account must be placed in the hands of an attorney or agency for collection, I agree to pay the holder’s reasonable fees and collection costs in addition to the outstanding balance. Collection methods include but are not limited to telephone calls, letters, use of collection agencies and attorneys, reports to credit bureaus and court action.

* Any balance due after 30 days may be assessed a $2.00 office fee per billing cycle.

Signature of patient _________________________ Date __________

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