Insurance coverage is an estimate, your actual cost may be more or less than what is covered by your plan. The responsible party will be held liable for all payments/copayment at the time of services, as well as any amounts not paid by your insurance. Unpaid mounts may include any fees denied by insurance,
not covered as estimated or unpaid account balances. By signing below you authorize the dental provider of services to release information required to secure payment of benefits and authorize this signature on all insurance submissions.