Wilson Martino Dental

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Wilson Martino Dental

Our entire staff is pleased that you have insurance benefits to help you and your family with the cost of your dental care. We would like to help you obtain the maximum use of these benefits, with this in mind, please read the information on our insurance claims process so we can work together to ensure this benefit.


We currently accept most private pay insurance plans, which mean that we work with hundreds of companies. Although we maintain computerized histories of payments by a given company, they do change; therefore, it is impossible to give you a guarantee quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is only an estimate. Also, if you have two insurances, we only accept assignment of your primary insurance. You are responsible for your secondary insurance. We will help you in any way possible with forms or calling your secondary insurance.


We base the patient portion of your bill on our most current data, but there are several factors that can affect this estimate. For example, there may be a deductible, or you may have received treatment in another office prior to joining our office. Insurance companies do not inform of us of any changes to your benefits. We do, however, investigate your benefits as thoroughly as possible.


We bill your insurance as a courtesy. Dental insurance is a contract between the employer and the patient. It has no connection at all to us as your dental office. The extent of coverage varies greatly from company to company, sometimes even within a company. It has absolutely nothing to do with the level of service provided by us, and the fees charged for these services.

An often misunderstood term used by insurance companies is “UCR”. This is an arbitrary fee ceiling at which the insurance company will stop reimbursement. These fee ceilings were often set 10- 15 years ago. After this ceiling, coverage for a particular procedure may cease, meaning that the patient will have an extra portion that is due. Despite our best efforts at giving you an accurate estimate, a patient will occasionally owe the amount of the difference. Again, this has nothing to do with the fees charged, but the level of coverage negotiated by your employer and decided upon by the insurance company.


We request payment for your portion at the time of service. We do have several methods of payment that are designed to help you and your families get the quality care that you deserve. Please feel free to ask any staff member if there is anything we can do to serve you.

We welcome you to our family and look forward to helping you get the healthy, beautiful smile that that you deserve.

In order to maximize your insurance benefits, please answer the following questions. This is very important in helping us determine your coverage, as you would be responsible for anything not covered:

  1. Have you ever used your dental insurance before? _______ yes _______ no

  2. Have you used any dental insurance benefits this year? _______ yes _______ no

  3. Do you know if you are eligible to receive your dental benefits at the present time? _______ yes ____ no

I have read, understand and accept the terms of the above outlined policies for insurance handling and financial commitments that I may incur as a result of treatment.

Responsible Party: Print Name________________________________________________

Responsible Party: Signature ________________________________________________

Patient: Print Name ________________________________________________________

Date _________________________

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