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Patient Financial Policy Notice


Thank you for selecting Broadmoor Dental for your dental care services. We are committed to providing the highest quality of care. As a courtesy to you, if applicable, we will bill your insurance company for any services rendered.

You have been/will be given a Treatment Plan Estimate detailing your estimated patient co-pays for any/all prescribed dental work. Insurance remittance estimates are provided as a courtesy and are based on current information collected from insurance carriers. While we would like to advise you of your exact financial obligation before your date(s) of service, the scale of different insurance plan designs make it extremely difficult. Your co-payment or patient portion may vary based on actual payments made by your insurance provider.

Claims for your dental care are submitted on the day treatment is completed. In the event your insurance carrier remits less than the estimated amount of the claim, for any reason inclusive of denied claims, the patient/responsible party, is financially responsible to pay the unpaid balance.

Bills for any amount due will be sent to you upon receipt of remittance or explanation of benefits by your insurance company. Payment is due within 10 business days from the date the bill is mailed. If payment is not received by the noted due date, it will be considered PAST DUE and may be sent to collections. Any questions or arrangements pertaining to your bill must be addressed within this 10 day period to keep this account in our office.

Financial Responsibility Agreement

Broadmoor Dental is committed to providing the highest quality care services to our patients. In return, I agree to be financially responsible for payment of Broadmoor Dental’s services.


I agree to give Broadmoor Dental complete and accurate insurance information for any primary/secondary insurance coverages. I understand that failure to supply complete and accurate information may result in denial of my claim or delay of insurance remittance. I understand that Broadmoor Dental has the right to close any unpaid claim that is older than 60 days from the date of service. I agree to pay any balance remaining on my account after my insurance claim(s) are processed.


I understand my financial responsibilities as they may relate to my dental insurance plan, and understand that any insurance portion(s) not paid by my insurance company(ies) are my financial responsibility. In the event of self-pay patients, non-insurance based treatment, I understand that I will be given a detailed treatment and fee estimate prior to any dental work being performed. I understand that I will be 100% financially responsible for the cost of such treatment.


I acknowledge that dentistry is not an exact science and changes in treatment may become necessary during the course of my care. I understand that I will be kept informed of any necessary changes and acknowledge that I will be financially responsible for any such changes.


I understand that any invoice or receipt issued by Broadmoor Dental is a non-binding estimate only, and additional charges may apply depending upon actual amounts remitted by my insurance company for services rendered. I agree to pay any balance remaining on my account within 10 days upon receipt of a statement requesting payment.


Please acknowledge your understanding of this notice and your willingness to comply with the above.