Office Financial Policies Form

Name*
First Last
Email*
Please type in your initial in each statement indicating you have read and understand it.
On the date of treatment, we require payment for either the exact or estimated patient portion. If we are unable to accurately determine your balance at your dental visit you will be required to pay a 25% deposit or leave a credit card number on file. This may result in a further balance to be paid by the patient or with the credit card number on file.*
Initial
Our office follows the Alberta General Dentist Fee Guide for the current year as set by the Alberta Government. You, the patient, are responsible for any difference in fees, and the same applies to patients with more than one insurance plan.*
Initial
If a balance remains after receiving payment from one or both insurance plans, we will contact you via your preferred method and charge the remaining balance to the credit card number on file. If a credit remains, we will contact you to arrange a refund or to leave on the account for future visits.*
Initial
Please be aware that not all treatments will be covered by your insurance. Each individual insurance plan has its own unique fee guide and limitations that you are responsible for understanding. Our administration team will do their best to help you understand the details of your insurance plan; however, due to privacy laws we are not permitted to access any information on your behalf from your insurance provider. It is the responsibility of the patient to inform us when changes occur in the insurance plan.*
Initial
The Administration team at White Oak Dental is happy to send your claim to the insurance directly for payment if you wish. Please select from the following options.
- OPTION 1 - Direct Billing. As a courtesy our Direct Billing Program offers you the convenience of billing your insurance company for treatment costs. This means White Oak Dental will receive the insurance payment and the patient is responsible for the amount not covered by the insurance.
- OPTION 2 - Fee for Service. This option allows you to be in control of your insurance benefits by paying in full at each appointment for your treatment and being reimbursed directly by your insurance company. If required, we will send electronic claims for you at each of your appointments.
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

7502