I understand and agree that I am personally responsible for the payment of all examination and treatment fees on my account. If my insurance company fails to make prompt payment, or denies payment for any reason, I will be responsible to make payment for the full amount without delay.
I understand and agree that I am responsible for the estimated amount not paid by my insurance company. This portion, plus the deductible, is due at the time of the appointment, when examination or treatment is rendered. I understand that after my insurance company makes payment, there may still be a balance remaining, for which I am responsible.
I have been informed if I hold a PPO insurance, I am responsible for amounts due after insurance pays. I am aware my insurance may be OUT OF NETWORK, resulting in my out of pocket being my responsibility. The staff has informed me OUT OF NETWORK policies and procedures.