PAYMENT FOR SERVICES
I understand that I am responsible for all charges for the care I receive. If I do not have dental insurance coverage, I will pay all amounts for which I am responsible in full, in advance of treatment. It is my responsibility to provide accurate and up-to-date information regarding my dental insurance coverage. I agree that payments from my dental plan may go directly to the practice. If I should receive the payments, I understand that I will be responsible for immediately paying such amounts to the practice. Depending on the type of coverage I have, my responsibilities are as follows:
IN NETWORK: If my treating dentist is in-network with my dental insurance plan, I will be billed pursuant to the terms of my insurance policy and my dentist’s contract with the insurer. Even when the practice and my treating dentist are a participating provider with my insurance, I understand that the practice may hold me responsible and collect all charges in any one of the following situations:
• When I choose to have a service that my dental plan covers but I do not obtain the required re ferral or prior authorization from my health plan.
• When I choose not to use my dental plan and agree to pay for se rvices myself.
• When I receive services that are not covered under my dental plan