Insurance Disclosure

Insurance fraud hurts you and your child/children, and can subject you to criminal and civil penalties.
Due to the serious nature of this offense and because this conduct may increase the exposure and
expenses incurred by this office, we must enforce this policy.
To ensure that we provide the best care and avoid any billing issues, it is essential that you notify us
immediately if there are any changes to your insurance coverage. Not doing so could result in
unnecessary charges to you financially.
PLEASE ENSURE you have notified our front desk staff of all insurance plans your child/children is
enrolled in, including PRIVATE and STATE insurance.

If insurance fraud is discovered after signing this form, Cornerstone Kids Dentistry is entitled to:
- Administrative fee $500
- Payment for any monetary difference between signed treatment plan and changes that result
from new insurance information.
- Refuse services and deactivate patient(s) from the office.
- Report of fraud to the proper authorities.

Why reporting changes is important:
- Accurate Billing: If we do not have your most current insurance information it could result in
delayed or incorrect billing, resulting in you being financially responsible for any visit.

- Avoiding Coverage Gaps: Changes to your coverage, such as plan updates or changes to your
benefits, could impact your treatment costs and services covered.

- Timely Processing: By informing us of any updates PRIOR to your visit, we can ensure smooth
processing of claims and prevent any unexpected costs to you.