Ty H.Barkley, DDS & Associates

2008 Exeter Road, Germantown, TN 38138 Phone 901/755-4132

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Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance company. In order to control cost of billing, we request that your co-payment be paid at the conclusion of each visit.

Insurance Authorization and Assignment: I hereby authorize Dr. Ty Barkley and Associates to furnish information to my insurance company concerning my child's dental condition and treatments and I hereby assign to the dentist all payments for dental services rendered to myself and for my dependents. I understand that I am responsible for any amount not covered by insurance.

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