Uparika Sharma D.D.S., P.S.
10655 N.E. 4th Street, Suite 308
Bellevue, WA. 98004
Phone: (425) 998-8109
Fax: (425) 450-1556
Email:AzaleaDentistry@gmail.com
About Financial Arrangements and Dental Insurance Consent for Services
We are committed to providing you with the best possible care. If you have dental insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy. If you sign up for new dental after your first appointment, even if it is the same company, please inform the office manager before any treatment is done. Your dental coverage may have changed.
We will be happy to process your insurance claim for reimbursement; however patient portion is due at the time services are rendered We accept cash, checks, MasterCard, Visa and American Express. Returned checks and balances older than 30 days may be subject to additional collection fees and interest charges of 1½% per month. There will be a charge of $50.00 per every hour scheduled assigned to your account for No Show appointments and appointments Cancelled without 48 hours advance notice.
Our office manager will gladly discuss your proposed treatment and answer any questions relating to your insurance. Please keep in mind: Dr. Sharma, the hygienist, and dental assistant do not have any knowledge of your insurance carrier, percentages, maximums or personal account balances. If you reserve an appointment without speaking with the office manager, you assume responsibly for coverage.
In addition, you must realize, that:
1. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.
2. Our fees are generally considered to fall within the acceptable range by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This applies only to companies that pay a percentage (such as 50% or 80%) of “U.C.R.”. “U.C.R.” is defined as usual, customary, and reasonable.
This statement does not apply to companies that reimburse based on an arbitrary “schedule” of fees, which bears no relationship to the current standard and cost of care in this area.
Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
We must emphasize that, as dental care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered.
In consideration for professional services, rendered to me, or at my request, I agree to pay my co-payment at the time of service. I further agree that services shall be billed unless objected by me, in writing within 5 days of billing. I further agree to pay all costs and reasonable attorney fees if suit is instituted hereunder.
If you have any questions about the above information or any uncertainty regarding your insurance coverage, PLEASE don’t hesitate to ask us. We are here to help you.
By my electronic signature below, I confirm that I have read the above conditions of treatment and payment and agree to their content.