Any unpaid insurance portion is your responsibility and is due before appliances are removed. Please inform us of any changes to your insurance at the time of the change. Insurance companies usually pay in increments of monthly, quarterly, semi-annually, or annually. Very rarely do insurance companies pay the benefit in one lump sum. If for some reason, the insurance terminates during treatment, the remaining insurance balance would be your responsibility (unless there is new insurance that might cover work in progress).
I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim.