Authorization, Release & Payment Options
Insurance authorization and flexible payment options to make dental care accessible and hassle-free.
The authorization and release form allows London Square Dental to coordinate directly with your insurance provider, submit claims on your behalf, and streamline the billing process. This ensures you can focus on your dental care while we handle the paperwork.
What This Form Covers
- Assignment of insurance benefits directly to London Square Dental
- Authorization for us to submit claims on your behalf
- Release of dental records to insurance providers as needed
- Consent for communication regarding appointments and billing
- Acknowledgment of patient financial responsibility
- Agreement to payment terms for services rendered
Payment Options Available
Direct Insurance Billing
We submit claims directly to your insurance company. For most patients, this means no upfront payment for covered services.
0% Financing
Split your treatment costs into affordable monthly payments with zero interest. Available for all procedures.
NIHB Coverage
We accept and direct bill Non-Insured Health Benefits for First Nations and Inuit patients.
CDCP Benefits
We are an approved Canadian Dental Care Plan provider. Eligible patients receive covered services with no upfront cost.
Multiple Payment Methods
We accept cash, Visa, Mastercard, Interac debit, and personal cheques for your convenience.
Payment Plans
For extensive treatments, we can arrange custom payment plans to fit your budget.
How to Complete This Form
The authorization and release form can be completed at our office before or during your appointment. Our front desk team will walk you through each section and answer any questions you may have.
If you have questions about insurance coverage or payment options before your visit, please call us at (403) 291-4945. We are happy to help you understand your benefits and financial options.
Looking for an Affordable Family Dentist in Calgary?
Join 4,800+ happy patients at London Square Dental Centre. Book a no obligation consultation today and receive a free professional whitening kit included with checkup and cleaning. Open 7 days a week with evening appointments available.
0% Financing Available