As a courtesy to me, I understand Bryan E Sorgen, DDS, PLLC will file any dental insurance claims on my behalf. I hereby authorize release of all information needed for such claims, and also authorize my insurance company to pay benefits accruing under my policy directly to Bryan E Sorgen, DDS, PLLC.  

I understand Bryan E Sorgen, DDS, PLLC will always do the best to help me maximize my dental benefits; however, my dental insurance policy is a contract between me, my employer and my insurance company. Bryan E Sorgen, DDS, PLLC is not a party to that contract. It is my responsibility to thoroughly understand the coverage and exceptions of my policy.  

My treatment plan is individually tailored based on my unique needs and is not based on my dental insurance benefits or lack of benefits. I understand that not all dental services are covered benefits in all contracts and some insurance companies arbitrarily select certain services they will not cover. Coverage issues can only be addressed by my employer or group plan administrator.  

I understand that my dental claim will be filed immediately, and benefits are expected to be paid within 30-45 days. The filing of an insurance claim does not relieve me of timely payment on my account. If the claim is not paid by my carrier in 60 days, I agree to pay the full remaining balance.  

I agree to be responsible for payment of all services rendered to myself and my dependents. I understand payment is due at time of service. I understand that my Social Security Number and any other information given will be used in order to collect any debt.