Timothy M. Hale, DDS
Board Certified in Periodontics

INFORMATION FOR OUR PATIENTS WITH DENTAL INSURANCE

Dental insurance is playing a larger role in helping people obtain dental treatment. Since we feel strongly that our patients deserve the best dental care we can provide and in an effort to maintain a high quality of care, we would like to share some facts about dental insurance with you.
We consider our relationship with you to be of primary importance. We always make our recommendations to you based on what we believe is the very best treatment for you regardless of you insurance coverage. As a patient, it is your responsibility to deal with your insurance company and your employer. We will assist in any way possible to maximize your dental insurance benefits; but to reemphasize, we have no relationship or responsibility to your insurance company.
FACT #1: Dental insurance is not meant to be "PAY-ALL," it is only an partial aid in paying for your dental care.
FACT #2:Many plans tell their insured that they will cover "up to 80%" or "up to 100%". In spite of what you are told, we have found many plans cover only 40% to 50% of the average fee. Some plans pay more....some pay less. The amount your plan pays is determined by the contribution you and your employer make to your dental plan. The smaller the contribution paid into the plan for "insurance" the less you will receive. It is you responsibility to advise us of your insurance coverage and restrictions.
FACT #3:It has been the experience of many dentists that some insurance companies tell their customers that "fees are above the usual and customary fees" rather then saying "our benefits are low". Remember you get back what you and your employer put into the insurance coverage less profits of the insurance company. In dealing with over 1000 dental insurance plans, most plans do not cover our fees.
FACT #4: Each plan utilized in our office has different percentages, deductibles, maximums, procedures covered and varying fees that the plan will allow. We will do our best to make as close a calculation as possible of what your insurance plan will cover. However, as we cannot estimate precisely, there may be variances for which the patient is individually responsible.
FACT #5Many routine dental services are not covered by insurance carriers. We make our recommendations based on your needs and not on what your insurance may or may not cover.
Please do not hesitate to ask us any questions about our office policy. We want you to be comfortable in dealing with these matters and we urge you to ask us if you have any question regarding or services and/or fees. We will do all we can to assures you of your maximum benefits.
If you have any questions regarding your insurance, please contact your insurance carrier regarding the specifics and details of the plan they are operating on your behalf.
[] I authorize the release of all necessary information.
[] I authorize payment of benefits directly to the provider.
[] I have read this form and agree to be financially responsible for all fees regardless of insurance coverage.

Signature: _______________________________   Date: _______________

Staff Signature: ____________________________  Date: _______________



Practice Limited to Periodontics and Implants
810 South Mason, Suite 325, Katy, Texas 77450, (281) 392-6000

American Academy of Periodontology: American Dental Association






























Insurance Information



Member's Name _____________________________  Relationship to patient _________________________

Member's SS# ______________________  D.O.B._______________  Day Time Number _______________

Insured's Employer _____________________________________  Patient's first Visit ___________________

Patient's name _______________________________  D.O.B.____________  SS# _____________________























For Office Use Only

Insurance CO. Name ______________________________________  Group # _______________________

Address_________________________________________________  Phone ________________________

Deductible $ _____________________ -Met ______ Y _______ N  Pre D required _______ Y _______ N

Payable at %__________ Max $ _______________ Used $___________ Remaining ___________________

Spoke to _______________________________ on _______ Notes ________________________________

______________________________________________________________________________________