While our practice accepts many forms of DENTAL insurance, we do not participate in any type of MEDICAL insurance. This means that unless you have one of the dental insurances we accept, you may have limited (or zero) insurance coverage for any procedures performed by our doctors. Your signature on this document indicates that you been informed of the following:

• You are ultimately responsible for any fees and balances.

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

• 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 not pay the facility or anesthesiologist or any associated claim when an out-of-network surgeon is used.

• Your MEDICAL insurance plan may not pay anything toward your oral surgery.

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