Assignment of Benefits

Assignment

I authorize payment of my dental insurance benefits directly to Esthetique Dentistry of Ashburn for services rendered, rather than to me.

I remain responsible for the balance

I understand this assignment does not relieve me of responsibility for any balance my insurance plan does not cover, including deductibles, co-insurance, amounts above my plan's annual maximum, and services my plan does not cover at all.

I understand that any estimate given before treatment is a good-faith estimate based on the information the plan has provided, and that my actual benefit may differ once the claim is processed.

Release of information for claims

I authorize the release of any information, including diagnosis and records of treatment, needed to process my insurance claims.

If the plan pays me instead

If my insurance plan sends payment to me rather than to the practice for services the practice has already provided, I will forward that payment to the practice promptly.