Dental Associates of Delaware
Financial Policies
Dental Associates of Delaware is not an agent of, nor is it associated with any dental insurance company. At the present time,
as a courtesy to our patients, we are happy to provide the service of completing, and submitting claim forms and receiving
payments from your insurance company. We will do everything legally possible to help maximize your insurance benefits.
I understand that my dental benefits are based upon a contract made between myself and my employer. I further
understand that Dental Associates of Delaware will make all reasonable efforts to help me communicate with my
carrier and do their best to obtain the maximum benefit for my treatment. However, they cannot assume
responsibility for my insurance company or their refusal to pay claims.
I understand that any pre-estimate, either determined by Dental Associates of Delaware or my dental benefit plan
is not a guarantee of payment. The benefit payment received is determined by my eligibility at the time of
treatment, deductibles, yearly maximum, family maximum and any other of the many criteria my benefit company
uses to determine benefits. Dental Associates of Delaware cannot guarantee payment or be held responsible for
multiple inquiries or requests by my benefit company.
I understand that dental benefits differ greatly from medical benefits. Dental benefit plans will never pay for the
completion of my dental care. It has always been meant to assist me.
I understand that many people receive notification from their insurance company that dental fees are “above usual
and customary.” I am aware that a dental benefits company determines their reimbursement level by surveying a
geographical area, calculating the average fee, and then determines that 80% of that average fee is customary.
Included in this survey are discount dental clinics and managed care facilities, which have severely reduced dental
fees that bring down the average.
I understand that many dental benefit plans tell their participants that they will be covered “up to 80% or 100%” but
do not clearly specify the plan fee schedule allowance, annual maximum or limitations. I am aware that it is more
realistic to expect dental benefit plans to cover between 25% to 40% of dental services. I am also aware that the
amount a plan reimburses is determined by how much my employer has paid for my dental benefit plan. I will get
back only what my employer has put in, less the insurance company’s profit margin.
I understand that dental benefit companies do not cover many routine and newer dental services. Dental Associates
of Delaware will gladly assist me in filling out the necessary forms to maximize my dental benefits and discuss my
financial options.
I understand that payment is expected at the time of treatment unless other arrangements have been made in
advance.
I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan unless
prohibited by law. To the extent permitted by law, I consent to your use and disclosure of my protected health
information to carry out payment activities in connection with this claim.
I hereby authorize and direct any payment of the dental benefits otherwise payable to me, directly to Dental
Management Strategies dba Dental Associates of Delaware.
Credits will be kept on accounts unless otherwise requested. If requested, refunds will be issued within 30 days of request.
I understand that I am financially responsible for all professional services rendered including, but not limited to, any balances
not covered by my dental insurance. A 1.5% monthly late fee will be assessed on all unpaid balances that are more than
ninety days past due from the date of service. I further understand that past due accounts will be placed with a collection
agency. I will be responsible for all costs of collection which may include collection fees, attorney fees, and any other fees
charged by the collection agency including but not limited to a fee for a partial payment made on a past due account.
