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Fees and Insurance
Orthodontics

mission

Our patients customarily pay for their treatment at each visit. We accept direct payment from several dental insurance plans, with prior authorization. Before insurance authorization, we must receive complete information about your plan.

In several of our clinics, individual payment plans and other arrangements may be made.

We take pride in the quality of care we provide at the University of Maryland Dental School. Here, you will find a dedicated staff to help you learn about the clinic best suited to your needs. Dental and dental hygiene students provide the majority of the treatment, supervised by a faculty engaged in teaching, research and patient care. At the Dental School, caring for you – and caring about you – is our goal. We can help you prevent dental disease, and can provide complete dental care for you and your family. Before we begin any treatment, we will conduct a complete examination to determine the best course of dental care. Our faculty review and evaluate all treatment provided by students. Your care may take longer, but you are assured of personal attention and supervision.


Financial Policy: Student and Resident Programs

All patients must sign this form prior to treatment. To save time please print this form and sign it prior to your appointment. (This requires Adobe Acrobat Reader, a free plug-in.)

Dear Patient:

Thank you for selecting us as your dental health care provider. The following information describes our Financial Policy. Our primary goal is that you receive the optimal treatments needed to restore and maintain your dental health. Therefore, if you have any questions or concerns about our financial policies, please do not hesitate to ask one of our office managers.

Payment for services is due at the time services are rendered. We accept cash, personal checks, and for your convenience Mastercard, Discover, American Express and Visa. We will help you process your insurance claim for your reimbursement as long as we have complete insurance information and you bring a completed claim form at your visit. In special instances, we accept assignment of insurance benefits.

  1. Your insurance policy is a contract between you, your employer, and the insurance company. We are NOT a party to that contract. Our financial relationship is with you, not your insurance company.
  2. All charges are your responsibility whether your insurance company pays or not. Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
  3. Fees for these services, along with unpaid deductibles and co-payments are due at the time of treatment.
  4. If the insurance company does not pay your balance in full within 30 days, we will ask that you contact the carrier to help speed things up.
  5. If the insurance company does not pay in full within 45 days, we will require you to pay the balance due with cash, personal check, Mastercard, Discover, American Express or Visa.
  6. Balances older than 90 days may be subject to additional collection fees and interest charges of 1.42% per month imposed by the State of Maryland Central Collection Unit. Returned checks will have an additional fee of $25.00 added to the amount of the returned check.

Please note that, unless canceled at least 24 hours in advance, you may be charged for missed appointments at the rate of a normal office visit. Please call your clinic as soon as possible if you have to reschedule.

We understand that temporary financial problems may affect timely payment of your balance. We encourage you to communicate any such problems to us so that we can assist you in the management of your account.

Again, thank you for choosing the Dental School as your health care provider. We appreciate your confidence in us and the opportunity to serve you.

Patient’s Signature:

Date:

U.M.FDSP. Associates, P.A.
Baltimore College of Dental Surgery
Dental School
University of Maryland at Baltimore
666 West Baltimore Street
Baltimore, Maryland 21201-1586


Commercial Insurance Policies

General Statement:

The Dental School accepts insurance reimbursement as direct payment for services rendered in all Pre and Post Doctoral Clinics as well as our Faculty Practice Dental Clinic. U.M. FDSP Associates; P.A. is a Preferred and Participating Provider with Blue Cross and Blue Shield of Maryland. We are not presently a member of any closed panel, managed care, or commercial HMO group. We will submit claims to your insurance company from all of the Dental School clinics so that either you or the Dental School may be reimbursed.

When registering, you are requested to complete the dental insurance section of the registration form as well as the Insurance Information Form, so that correct information may be gathered and incorporated as part of your dental and financial records. At your initial appointment with your assigned provider, you are further requested to bring a copy of your carrier’s insurance form with all pertinent employee and patient information completed. The form must also contain the patient’s signature authorizing submission of information, and where applicable, authorization to pay benefits to the provider.

If after your treatment planning visit, the estimated fees exceed $250.00, a preauthorization request will be forwarded to your dental carrier for a determination of benefits. Both you and the Dental School should receive a copy or the carrier’s determination. Definitive care will be delayed until this authorization is received and discussed by the patient, provider, and the appropriate financial advisor. As treatment is completed, a request for payment will be forwarded to your dental carrier. The School’s business office will forward these forms.

Each calendar year you are requested to provide us with a completed and signed insurance form for our files. This form for claiming dental benefits is usually provided by your insurance carrier. If no such form is provided by your carrier, we will provide you with a generic form upon your request for your signature. If for any reason, your dental coverage changes during the course of your treatment, you are required to notify us of the changes and provide us with a complete update of the new information along with a signed claim form. Failure to provide this information may result in a delay of treatment and/or a denial of insurance coverage.

Patients who are insured with closed panel dental carriers, managed care, or other preferred provider programs, must be treated by approved providers in order to utilize their dental benefits. Patients who carry this type of insurance should check with their carrier or refer to their insurance manual for further advice.


Participation with the following Insurance Companies (as of September 1999; please verify that your plan still particapates)

Blue Cross Blue Shield (DENTAL)

  • Federal
  • Preferred Provider
  • Traditional

Aetna - Limited Plan - Included employeers:

  • Oracle
  • Andersen Worldwide
  • USF&G
  • Overnite Transportation
  • Aetna Inc

Cigna

GEHA

Metropolitan Life

EHP

Tricare Family Member Dental Plan

Health Choice HMO's

  • Maryland Physicians Care
  • Priority Partners
  • Americaid
  • George Washington University
  • HELIX
  • United Health Care

Dental Value Membership - Employer/Employee Program

  • Lorien Nursing & Rehab Center
  • Group Benefits Services
  • Associated Dental Plan
  • Local Goverment Insurance Trust
  • First Health
  • Health Plan for USA
  • Principal Health
  • Uniformed Services Family Health Plan

Medical Providers with:

  • Blue Cross Blue Sheild Only

Insurance Information Form

Please have the following information available upon arrival. 

To save time please print this form and fill it out prior to your appointment. (This requires Adobe Acrobat Reader, a free plug-in.)

Insurance Information Form

Patient:_______________________________

Record #__________

Relationship to Employee:

____Self

____Spouse

____Child

____Other

Employee/Subscriber Name:_____________________________________

Employee/Subscriber Social Security Number: _ _ _ - _ _ - _ _ _ _

Employee/Subscriber Date of Birth: _____ /_____ /_____

Employer (Company) Name and Address
                                                             _________________________

                                                             _________________________

                                                             _________________________

Insurance Company Name, Address and Phone Number:

                                                             _________________________

                                                             _________________________

                                                             _________________________

                                                             ( ______ ) ______ - ________

Group Number (if Applicable):

Policy Anniversary Date:

Do you have a copy of your benefit booklet?   ____Yes   ____No

Do you know the deductible amounts
and/or percentage of reimbursement?            ____Yes   ____No

If you have a copy of your dental benefit booklet, please bring it with you to your appointment with your assigned dental care provider for verification by our staff. You are requested to bring a copy of your insurance form with all pertinent employee information completed and signed where appropriate. Failure to provide necessary information may result in delay of treatment and/or denial of insurance coverage.

Thank you for your cooperation.


Medical Assistance Program (Title 19)

The Dental School is a provider with the Medical Assistance Program and as such accepts patients for treatment who are less than 21 years of age. These patients may receive emergency or comprehensive dental care upon presentation of a valid Medical Assistance Identification Card issued by the State of Maryland or the Federal Government. Patients 21 years of age or older are not covered for routine dental services.

The eligible patient must present a valid M.A. card at each visit. At the time of registration, the M.A. card number will be verified and recorded. If the patient presents an valid card during the course of treatment, it is the provider's responsibility to take the card to the appropriate office for proper documentation.