initials* First and foremost, it is the responsibility of the patient/guardian to inform Carter Orthodontics of any/all insurance changes as soon as possible (students status change, changes in employment from full-time to part-time, changes in employer, termination of coverage, address change, etc.). Failure to do so may result in insurance non-payment. Any unpaid insurance balance will become the patient’s/guardian’s financial responsibility.

initials* Checks received from insurance by the subscriber are to be turned over to Carter Orthodontics. Failure to do so is insurance fraud and may be reported to the Insurance Commissioner.

initials* Most insurance companies have an orthodontic age limit (anywhere from 19-25 depending on insurance). If the patient reaches this pre-determined age limit while in active treatment, orthodontic coverage stops. Any unpaid insurance balance due to an age limit restriction will become patient’s/guardian’s financial responsibility.

initials* Most insurance companies pay for orthodontic services over the length of active treatment as opposed to in a lump sum. Cancellation of coverage during active treatment and/or employment change will result in any unpaid insurance balance becoming patient’s/guardian’s responsibility. Employment change may alter orthodontic benefit reimbursement amount.

initials* Oral Surgery/extractions and/or exposures are considered to be orthodontic in nature. Please be aware that this will affect the orthodontic lifetime maximum and may result in coverage substantially less than originally quoted prior to treatment. Any unpaid orthodontic balance will become patient’s/guardian’s financial responsibility. Carter Orthodontics files insurance as a courtesy for our patients. There is no guarantee of payment once a claim has been filed. By initialing/signing, you are verifying that the above has been explained and is understood.