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Insurance Worksheet

MarketDental Inc. - 18035A 107 Avenue NW, Edmonton, AB, T5S 1K3

Insurance Worksheet
Your particular dental plan may or may not cover the full cost you incur for your necessary dental treatment. This can occur because fees in our office are based on factors and fee guides, which may or may not have been considered by your employer when enrolling in your plan. In addition, there may be certain dental procedures performed which are not covered by your individual policy. Our office will accept direct payment from your dental plan for the cost of those dental services we provide that are covered by your individual policy, however, there are many variations of individualized treatment and it is almost impossible for us to know the details of individual policies. With many privacy laws in effect, it prevents us from obtaining detailed information on your behalf regarding your individual coverage. For this reason, we ask for your understanding if we are unable to provide financial details pertaining to your insurance at the time the treatment is recommended by the dentist or dental hygienist. We will, however, strive to provide the most accurate estimate possible prior to starting treatment. In order to answer your financial questions there are some basic information from your insurance that we request. We ask that you call your insurance company and ask the questions listed below. We will keep this document on file to better assist you when a member of our dental team is discussing your treatment and fees.
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How many units of scaling (cleaning) am I covered for?
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How many units of root planning (deep cleaning) am I covered for?
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How often am I covered for?
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I have read the above and agree to assume full liability for fees not covered by my insurance plan.
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