Our primary goal is not to allow the cost of treatment to prevent you from benefiting from the quality care you need or desire. In our office, we strive to maximize your insurance benefits and make any remaining balance easily affordable. Our fees are based on the quality materials we use and the time, effort and skill required in performing your needed treatment. We charge what are the usual and customary fees for our area. We will assist you with your benefit eligibility before treatment to help you calculate your costs and maximize your insurance. We·will be sensitive to your financial circumstances and do everything possible to help you achieve oral health. Ultimately, however, you are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. We are happy to submit the claims necessary to see that you receive the full benefits of your coverage; however we cannot guarantee any estimated coverage. Because the insurance policy is an agreement between you and the insurance company, we ask that all patients be directly responsible for all charges. Please know that we will do everything possible to see that you receive the full benefits of your policy by electronically filing your claim the day of your appointment. Patients are expected to pay for their services at the time they are rendered. Our patients who have dentaI insurance are expected to pay the amount of their estimated co-pay and deductible at the time of service . Payments may be made using cash, check, Visa, MasterCard and/or Discover. We also offer CARECREDIT, which is a financing option that is available only for healthcare expenses. Optional payment terms: 1. Full Pay CASH Discount: We offer a 5% accounting courtesy for all services over $500 that is paid in full prior to the commencement of services that is paid by cash or check. Payment must be paid 24 hours prior to treatment. 2. Full Pay CREDIT CARD Discount: We offer a 3% accounting courtesy for all services over$SOO that is paid in full prior to the commencement of services that is paid with a Visa. * *Sorry this discount does not apply to Discover Card or American Express. Payment must be paid 24 hours prior to treatment. 3. Payment Plan: CARECREDIT we can offer patients upon approval, an interest-free payment plan (up to 12 months) with no down payment, no annual fee and no prepayment penalty. Ask for an application. We reserve the right to assess a fee of $35.00 fee for returned checks, and additional banking fees.

I understand that I may inspect or copy the protected health information described by this authorization. I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form. I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality,

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns. I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.