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 referral or prior authorization from my health plan.
- When I choose not to use my dental plan and agree to pay for services myself.
- When I receive services that are not covered under my dental plan
OUT OF NETWORK: If my treating dentist is not a participating provider with my insurance, I will be required to pay for all treatment in full, in advance. The practice may file for insurance coverage as a courtesy and apply anything they pay towards my account. If payment from my insurance company results in an overpayment on the account, I will be reimbursed by the practice.
ALL PAYORS: Regardless of whether my treating dentist is participating provider, I will be responsible for any deductibles, co payments, the costs of uncovered services and any other part of the bill that my dental plan says I must pay. If for any reason I do not pay, in full, the amounts I owe the practice, I will also reimburse the practice for all costs of collection, including legal fees and a 25% collection fee of the total amount submitted to the collection agency. I also agree the practice may charge me interest equal to 2% monthly on all balances that have been outstanding for thirty (30) days or more.
RELEASE OF INSURANCE BENEFITS
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 dentists 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 CORDENTAL Group’s use and disclosure of my protected health information to carry out payment activities in connection with insurance claims. I hereby authorize and direct payment of the insurance benefits otherwise payable to me, directly to CORDENTAL Group and its partnered affiliates.