Insurance & Financial Policy Form for New Patients

First Name:

Last Name:

Date of birth:

Please CHECK all applicable items:

I authorize release from my insurance company plan administrator and CDA the information contained in insurance claims submitted electronically or by mail at South Simcoe Dental Care.
I hereby assign my benefits payable from insurance claims submitted electronically or by mail to Dr. M. Laureola at South Simcoe Dental Care and authorize payment directly to him.
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor and staff at South Simcoe Dental Care at my next appointment without fail.

Financial Policies

The benefits you receive from your insurance company are between you, your employer, and your insurance carrier. Any benefit difference is your responsibility, which includes deductibles, fee guide differences, ineligible services, or copayments.
Payment for services rendered is due on the day of treatment, unless otherwise specified in a written financial arrangement or if South Simcoe Dental Care has been assigned benefits directly from your insurance carrier.
All estimates for care are approximated.
A service charge of 1.5% per month (18% per year) on the unpaid balance will be charged on all accounts exceeding 90 days, unless previously written financial arrangements are satisfied.

Insurance Estimates and Authorization

I understand that all dental treatment estimates are approximate and not guaranteed. At times, my dental provider may need to submit treatment estimates (pre-determinations) to my insurance company to verify eligibility, coverage, and benefits. I authorize the dental office to release any necessary information to my insurance carrier for the purpose of obtaining these benefits and confirming coverage.
I also understand that my insurance company may deny or adjust coverage, and I am responsible for any fees not covered by my plan.

Canadian Dental Care Plan (CDCP) Financial Clause

I understand that eligibility and coverage under the Canadian Dental Care Plan (CDCP) are determined solely by the Government of Canada. I am responsible for confirming and maintaining my eligibility, including timely renewal of my CDCP coverage.
I acknowledge that CDCP may not cover all services or the full cost of treatment. I agree to be financially responsible for any non-covered amounts, including co-payments, non-eligible services, and fee differences. The dental office is not liable for denied or reduced claims, and payment for uncovered portions is due at the time of service.

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor and staff at South Simcoe Dental Care at my next appointment without fail.

I have read the above conditions of treatment and payment and agree to their content

Initials of patient, parent, guardian or guarantor of payments:

Relationship to Patient: