Our practice and all of our surgeons participate with CareFirst Blue Cross Blue Shield medical insurance plans only. In the event that any treatment performed by our surgeons falls within your medical benefits (even when medical denial is requested by your dental insurance); we will submit a claim to your medical insurance carrier. However, if the insurance company is not CareFirst Blue Cross Blue Shield, we are non-participating providers and you may not have coverage or limited coverage for any procedures performed by our doctors. It is for this reason that your signature on this document indicates that you understand all of the following:

• Payment is due directly from you.

• We will provide the codes for the planned procedures, which you can use to contact your insurance about possible benefit information. You will need to let them know the surgeon is “out of network”, as that may make a difference in coverage.

• As a courtesy to you, we will file a claim to your insurance company with all the necessary documentation but will not assume any responsibility on the claim and/or the insurance company guidelines or regulations.

• We do not verify whether pre-authorization is required for procedures/scans performed in our office.

• If your surgery is done at a hospital or other facility, it is possible that your insurance will consider a payment for the facility or anesthesiologist charges but they may NOT consider a payment for procedures associated with our out-of-network surgeon.

• Your insurance plan may not pay anything towards your surgery or a deductible might need to be satisfied before any benefits are considered.

If you have questions or concerns about this information, please discuss them prior to signing this form. There are no exceptions to this policy.