Responsible Party (If someone other that the patient)
Primary Insurance Information
Secondary Insurance Information
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Dental Insurance & Financial Policy Disclosure
FULL PAYMENT for all dental services provided in our office is the responsibility of the patient or patient’s parent or guardian. If you have a dental insurance plan, our office will assist you in submitting claims as a courtesy, but you will be responsible for any difference in fees.
Our office submits insurance electronically every day. It is your responsibility to keep your insurance and personal information current in our files.
Please understand that all insurance plans are not equal. Among the different insurance plans and even within the same company, there are considerable differences in rates and allowances. Because of this our office cannot verbally estimate what your insurance will pay.
If you have concerns about what your insurance will pay, please request a pretreatment estimate before treatment is done. We usually allow 4-6 weeks for a response from the insurance. A letter will be sent to you indicating the estimated amount insurance states they may pay and what your responsibility is. Remember, this is always only an estimate and does not guarantee payment from your insurance. Actual benefits are not determined until the services are completed.
Our office participates as a provider for United Concordia (former BCBS Plans) and Delta Dental Premier. We are not providers for MN Medicaid/MN CARE, and do not submit claims, you will be responsible for payment on the day of service.
I understand that my insurance plan may contribute a portion of the payments due Sandman Family Dentistry, LTD DBA Insight Dental Associates.
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