I UNDERSTAND THAT I AM PERSONALLY RESPONSIBLE FOR CHARGES INCURRED FOR SERVICES RENDERED BY Center Of Dental Services IF ANY OF THE FOLLOWING APPLY:
My health plan requires prior authorization before receiving
services and I have not obtained such an authorization or I
received services in excess of such authorization.
My Dental plan coverage has lapsed or expired at the me I
- I have chosen NOT to use my Dental plan coverage
I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CO-PAYMENTS AND
CO-INSURANCE SUMS UNDER MY DENTAL PLANS.
I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR THE BALANCE OF THE
BILL THAT IS NOT PAYABLE BY MY INSURANCE PLAN OR SECONDARY PLAN.
FURTHERMORE, I AGREE, THAT IF LEGAL ACTION BECOMES NECESSARY DUE
TO MY FAILURE TO PAY MY RESPONSIBILITES, THE COST OF THAT ACTION
TOGETHER WITH INTEREST, ALLOWED BY LAW, WILL ALSO BE PAYABLE BY