Quote of Insurance Benefits Form

Summary of Quote of Benefits Received from Your Insurance Company

  • The first section is a summarized quote of benefits we received from your insurance company. If you scroll toward the end of the page, there is a section that will explain what this quote means for you.

    All unpaid balances and/or denied claims are ultimately patient responsibility. Please contact our office with any questions.
  • Benefit Max:
  • End of Insurance Quote Information

  • What Does This Mean For You?

    The following information gives you an estimate of what your cost per appointment may be. These estimates are based on the quote we received from your insurance company. The actual amount will vary depending on treatment performed at each visit. Please consult your EOB for final amount owed.
  • BENEFIT DISCLAIMER: Please note this is a quote of benefits and not a guarantee of payment by your insurance. Final determination of a claim payment will be made once your insurance company received your claim for services rendered. Deductible and out of pocket amounts will change as additional claims are processed by your insurance.
  • Insurance Terms Cheat Sheet:
    Co-insurance:  A percentage of the total payable amount that you will owe for each date of service.
    Co-pay:  A fixed dollar amount to be paid by you before your insurance company will pay out benefits.
    Deductible:  An amount set by your insurance policy that must be paid out-of-pocket before your insurance company will start to pay our benefits. Once met, you still may owe for co-insurance or co-pay amounts.
    EOB:  Explanation of Benefits 
    N/A:  Not applicable
  • Signature Line is for In-Office use only.