This authorization will remain in effect until revoked by the patient.
Monday through Friday from 8am to 6pm.
If you cancel an appointment with less than 24 hours’ notice you will be charged a fee.
If you no show an appointment you will be charged a fee. If you no show an appointment a 2nd time Carolina Dental may refuse to continue to offer treatment.
The fees for Canceling / Breaking appointments are as follows:
**ALL CO-PAYS FOR SERVICES RENDERED ARE DUE AT THE TIME OF SERVICE**
We will make every attempt to get your claims paid. Insurance companies will not guarantee payment or eligibility but we will make every attempt to be as accurate as possible with estimations. If an insurance company refuses payment on a claim you will be responsible for any remaining balance not covered.
Most common denial by insurance companies:
Alternate Benefit: This is when an insurance company decides to down grade a filling or crown. Resin filling (tooth colored) to an amalgam filling (silver) or a tooth colored crown to a silver crown. If your insurance company chooses to pay the alternate benefit you will be responsible for the difference.
I authorize and request my insurance company to pay directly to the dentist or dental group my insurance benefits that would otherwise be payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or for my dependents.
I have received a copy of the Notice of Privacy Practices for the above named practice.