As a courtesy to you, this office will file your dental insurance; however, we are not a preferred provider or an in-network dentist. Different insurance policies pay varying percentages for dental procedures and therefore it is not possible to estimate the exact amount of charges owed by the patient. If there is a refund or a balance due, you will be notified accordingly within 30 days of receipt of insurance payment. Any charges not paid by insurance within 60 days of filing are the responsibility of the patient, including any interest accumulated at a monthly periodic rate of 1.5%. I understand the insurance information above and agree to these terms. If I am uninsured, I realize that all charges for treatment are my sole responsibility at time of service.