INSURANCE INFORMATION

You WILL BE GIVEN AN "ESTIMATED" PORTION FOR YOUR DENTAL TREATMENT THAT IS NEEDED, THIS IS ONLY AN ESTIMATE SOME TEETH MAY
HAVE HIDDEN DECAY, OR AFFECTED NERVES, REQUIRING MORE EXTENSIVE DENTAL TREATMENT AND ADDITIONAL COST/ PAYMENT IS DUE AT THE TIME OF SERVICE., WE WILL ASSIST OUR PATIENTS WHO HAVE INSURANCE BY FILING THE NECESSARY FORMS. PLEASE BE ADVISED YOUR INSURANCE COMPANY WILL PAY A PERCENTAGE OF OUR FEES AS DETERMINED BY YOUR INSURANCE COMPANY (REFEREED TO USUAL, CUSTOMARY,AND REASONABLE FEES), NOT NECESSARILY THE ACTUAL FEE CHARGED BY DR. CASTRO. YOU WILL BE THE RESPONSIBLE FOR THE DIFFERENCE BETWEEN DR.CASTROS'S FEES AND THE FEE "SUGGESTED"
BY YOUR INSURANCE COMPANY, SHOULD THERE BE ONE.
                                                                                                                                                                                        DR. CASTRO IS ONLY A LISTED PROVIDER FOR SOME OF THE FOLLOWING INSURANCE PLANS UNDER DELTA (** we are no longer accepting new patient with Delta Insurance), BLUE CROSS, AND GUARDIAN.
OTHER INSURANCES WHERE YOU HAVE THE "FREEDOM OF CHOICE" WE WOULD GLAD SEE YOU AND BILL YOUR INSURANCE. AS WITH ANY INSURANCE PLAN WE CAN NEVER GUARANTEE EXACT PAYMENT. ULTIMATELY YOU 
ARE RESPONSIBLE FOR ANY UNPAID BALANCE AFTER YOUR INSURANCE PAYMENT HAS BEEN RECEIVED BASED ON OUR FEE, NOT NECESSARILY THE AMOUNT PAID BY YOUR INSURANCE.                                                                                                                                                                




                                                                     FINANCIAL AGREEMENT/ASSIGNMENT OF BENEFITS

I HEREBY GIVE AUTHORIZATION FOR PAYMENT OP INSURANCE BENEFITS (AS LONG AS I AM A PATIENT OF RECORD') BE MADE DIRECTLY TO DANIEL CASTRO,DDS FOR DENTAL SERVICES REDDENED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER. OR NOT THEY ARE COVERED BY INSURANCE. IF FOR SOME REASON MY ACCOUNT SHOULD BECOME DELINQUENT (AFTER 30 DAYS) I AGREE TO PAY THE INTEREST CHARGES OF 18% ON THE UNPAID BALANCE. OUR OFFICE FILES YOUR INSURANCE AS A COURTESY TO ALL OUR PATIENTS AT NO CHARGE IF AFTER 30 DAYS WE ARE UNABLE TO COLLECT FROM THEM IT WILL BE YOUR RESPONSIBILITY TO CORRESPOND WITH YOUR INSURANCE COMPANY AN ATTEMPT OF PAYMENT. IN TEE EVENT OF DEFAULT, I AGREE TO PAY ALL COSTS OF COLLECTIONS AND REASONABLE ATTORNEY'S FEES. I HEREBY AUTHORIZE MY DENTAL CARE PROVIDER TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF BENEFITS.


         SIGNATURE                                                                                                                                                                                                                                                         DATE



           DANIEL CASTRO, DDS 965 NORTH RESLER, SUITE 105 EL PASO, TEXAS 79912