Insurance “SIGNATURE ON FILE” Authorization

First Name:
Middle Initial:
Last Name:
Insured's First Name:
Insured's Last Name:

Understading your orthodontic Insurance

If you have dental insurance, we will file the claims for you as a complimentary service. It is very important that the correct information is provided at the time of the patient’s appointment. If this information changes, it is the patient’s responsibility to update McBride Orthodontics as soon as possible. While we do our best to verify dental insurance benefits, the insurance company is very clear that the benefit information we are given is an estimate and no guarantee of payment. We will provide you with a verbal estimate of your insurance benefit we obtain from your dental insurance for the planned treatment, however, please understand that these are estimates and are not a guarantee of payment.

As of October 1, 2023, we are no longer accepting assignment of benefits. Insurance payments will be paid directly to the holder of the insurance policy either monthly, quarterly, or annually depending on the terms of the policy. It is a rare exception that a one-time payment for the entire lifetime maximum is initially made. Typically, insurance will pay a portion for the initial bonding and the remaining benefit will be prorated over the remaining months of treatment. If an insurance payment is ever sent directly to our office, we will apply it to your account. While the filing of the claim is a courtesy that we extend to all of our patients, the total treatment fee is your responsibility from the date the services are rendered. Our office offers interest fee monthly payment options after a down payment is made prior to the treatment start date.

During orthodontic treatment, if insurance coverage is interrupted for any reason, (eg. In employment, a change in your employer’s insurance companies, a drop in coverage, or treatment that is completed early) insurance payments stop. If new insurance is obtained during treatment, it is the patient’s responsibility to inform the office so that we can file a new claim on your behalf. Some insurance companies have clauses that will not allow full benefits to be paid if the treatment started prior to the takeover by the new insurance policy. The benefit may be prorated, or the claim may be denied at the discretion of the insurance company.
I understand and agree that the total treatment fee will be paid to our office up front or via payment plan, and insurance payments will be paid directly to the insurance policy holder.
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I authorize the release of all medical information to the insured’s insurance carrier that is acquired during the course of any treatment, which may have a bearing on the benefits payable under this or any other plan.
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I authorize Dr. Matthew D. McBride or any of their agents to assist me in submitting insurance claims to my insurance company and have the authorization for use of any insurance on the patient’s behalf.
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I authorize my signature on this form to be used as “signature on file” for electronic submissions of my insurance claims.
Signature:
I have read and fully understand all the information provided to me regarding my insurance “estimate” for payment.
Signature:
I understand that it is the responsibility of the insurance policy holder to obtain any insurance payment(s) that are not received by the insurance company in a timely manner according to their fee schedule.
Signature:

Patient/Guardian Signature:
Date:

Notice of Privacy Practices

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patients’ Rights section describing your rights under the law. You have the right to review our Notice before signing the Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office or going to our website.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent in writing, signed by you. However, such revocation shall not affect any disclosures that have already been made in reliance on your prior Consent. McBride Orthodontics provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

The Patient Understands that:
  • Protected health information may be disclosed or used for treatment, payment, or health care operations.
  • McBride Orthodontics has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
  • The Patient has the right to restrict the uses of their information.
  • The Patient may revoke this Consent in writing at any time and all future disclosures will then cease.
  • McBride Orthodontics may condition treatment upon execution of this Consent. No insurance can be billed on the patient’s behalf without signed HIPAA consent form, therefore same day of service payment in full for any services will be required.
Patient/Guardian Signature:
Date:

Authorization for Communication and Social Media

McBride Orthodontics may use and disclose protected health information about me to carry out treatment, payment and orthodontic care. Please refer to McBride Orthodontics' Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practice at any time.
McBride Orthodontics may call to leave a message on my answering machine/voicemail and may leave a message with whoever answers my home phone. McBride Orthodontics may also send mail or email to my home in reference to any items that assist the practice in carrying out treatment, payment and health care operations such as appointment reminders, billing information, insurance items, newsletters, contests and promotions.
My preferred method of communication, please check the appropriate boxes below:
If the above method of communication is by phone, please check the appropriate box below:
I understand that any and all records, whether written, oral or in electronic format are confidential and cannot be disclosed for reasons outside of treatment, payment and health care operations. I understand and have been provided with a Notice of Patient Privacy handout that provides a more complete description of information uses and disclosures. A photocopy or fax of the consent is a valid as this original. I understand that I may revoke this consent, in writing, except where disclosures have already been made in reliance on my prior consent.

Signature:
Date: