Jorge Oaxaca DDS, Inc. and Howard Ong DDS, FAGD, Inc.

Restorative, Cosmetic and Implant Dentistry

Do You Have Insurance that Assists You?

à We are thrilled that you have assistance from an outside source for your dental needs. Please note, however, that dental insurance is truly only meant to aid in the cost of some treatments. Most dental plans only pay a portion of each procedure and/or have a maximum limitation per year. Because of this reality, you, as the patient, are responsible for payment of all treatment balances regardless of an insurance company’s determination of coverage.

à As courtesy to you, our administrative staff is happy to process dental insurance claims on your behalf. We will make every effort to assist you in maximizing your insurance reimbursement for covered procedures. There are a limitless number of dental insurance carriers as well as a myriad of group plans that are on the market. It is important to us that you understand that the contract regarding your dental benefit package is between you and your insurance company. Our office is not a party to that contract and is ultimately not responsible for how your insurance handles your claims or for the benefits they provide. Because of this fact, we cannot guarantee that your insurance company will pay for the treatments you receive from our practice.

à It is rare, but on occasion there may come a need to deliberate with an insurance company over their payment on a claim. Our office will not enter a dispute with your insurance over any claim. We will, however, provide necessary documentation your insurance may request to sort out any confusion or questions that arise. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.

Insurance Assignment and Release

I certify that I am currently covered by insurance with ________________________________and assign directly to Jorge Oaxaca DDS, Inc. and Howard Ong DDS, FAGD, Inc., all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions.

Jorge Oaxaca DDS, Inc. and Howard Ong DDS, FAGD, Inc. may use my health care information and

may disclose such information to the above-named Insurance Company(ies) and their agents for the

purpose of obtaining payment for services and determining insurance benefits payable for related

services. This consent to remain in effect until cancelled in writing.

I have read and understand the above terms and conditions.

_____________________________________________________ ___________________

Signature of Patient or Parent/Guardian Date

Jorge Oaxaca DDS, Inc. and Howard Ong DDS, FAGD, Inc., 805 Central Avenue, Seal Beach, CA 90740

562.596.1621

www.sealbeachdds.com