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PRINT OUT FORM - COMPLETE FORM - BRING FORM TO APPOINTMENT
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Acacia Endodontics, Lance P. Schneider, D.D.S. / Shaun R. Cullimore D.M.D.
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Dental Insurance is a contract between you, your employer and your insurance carrier. Your dental insurance is not a contract between your insurance carrier and your doctor, unless your doctor is a panel provider for your insurance carrier and has contracted to a specific fee schedule with your carrier.
Discount Dental Plans are just that - discounts. These plans allow you to purchase specific dental procedures for a discounted fee(s).
The reimbursement levels will vary from one insurance carrier to another. One carrier may say they pay 80% for root canal treatment (endodontics), when what they actually pay is 80% of the carrier's fee schedule, which is usually far below actual fees for our geographic area. Thus, we can see there is usually a discrepancy between the insurance carrier and the real world.
Our office will file for you, at no cost to you, your insurance claim with your carrier at the time of services. You must provide us with accurate and complete data to properly obtain for you the maximum reimbursement levels. Our office will not be able to trouble-shoot claims which are delayed and/or contested by your carrier. However, we will provide you carrier copies of x-rays and/or written narration on your claim should your carrier require this level of documentation. Insurance claims assigned to our office and not paid by your carrier after thirty (30) days will be billed back to you, the patient, and are then due in full within ten (10) days. After sixty (60) days, unpaid accounts will go to collections. It is therefore very important that you take an active role in following your claim by telephone with your insurance carrier. Your involvement will speed things along! Should you have a severe problem with your insurance carrier, contact your Human Resources Officer at your place of employment. They often can solve the problem quickly.
We adhere to the most current technology available to date. Due to this use of state of the art equipment, some procedures performed in this office may not be a covered benefit of your insurance policy. THEREFORE, THESE FEES ARE THE PATIENT/GUARDIAN RESPONSIBILITY.
Should you have any questions, please ask a staff member, and we will do our best to assist you within our limits of expertise.
Agreement: I am aware that I am responsible for payment of this account and if the use of a third party becomes necessary to secure payment, I am also responsible for all collection/attorney fees and court costs.
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Patient (Guardian): __________________________________________
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