Out of Network. Covered for Medical Base Plan with $600 deductible and 70% coinsurance up to the annual out-of-pocket maximum. Pre-arranged services while outside the area are covered as if in-network.
Out of Network. If my treating dentist is not a participating provider with my insurance, I will be required to pay for all treatment in full, in advance. The practice may file for insurance coverage as a courtesy and apply anything they pay towards my account. If payment from my insurance company results in an overpayment on the account, I will be reimbursed by the practice. ALL PAYORS: Regardless of whether my treating dentist is participating provider, I will be responsible for any deductibles, co- payments, the costs of uncovered services and any other part of the xxxx that my dental plan says I must pay. If for any reason I do not pay, in full, the amounts I owe the practice, I will also reimburse the practice for all costs of collection, including legal fees and a 25% collection fee of the total amount submitted to the collection agency. I also agree the practice may charge me interest equal to 2% monthly on all balances that have been outstanding for thirty (30) days or more. RELEASE OF INSURANCE BENEFITS I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law or the treating dentists or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to CORDENTAL Group’s use and disclosure of my protected health information to carry out payment activities in connection with insurance claims. I hereby authorize and direct payment of the insurance benefits otherwise payable to me, directly to CORDENTAL Group and its partnered affiliates. MY SIGNATURE BELOW ACKNOWLEDGES THAT I HAVE READ THIS CONSENT AGREEMENT AND AGREE TO THE STATED ITEMS AS THEY HAVE BEEN OUTLINED. I HAVE BEEN GIVEN THE OPPORTUNITY TO HAVE MY QUESTIONS ANSWERED AND UNDERSTAND THAT I MAY MAKE INQUIRY TO THIS AGREEMENT AT ANY TIME. I FURTHER ACKNOWLEDGE THAT I MAY REVOKE MY CONSENT TO ALL OR ANY PART OF THIS CONSENT AGREEMENT AT ANY TIME BY DOING SO IN WRITING. _ PATIENT NAME (PRINTED) DATE _ SIGNATURE OF PATIENT/LEGAL RESPRESENTATIVE _ RELATIONSHIP TO PATIENT
Out of Network treatment by a Dentist who has not signed an agreement with Delta Dental to provide Benefits under the terms of this Contract.
Out of Network. Examination – once a calendar year Covered 100% (after $6.50 co-pay) Optometrist reimbursed up to $28.50 Ophthalmologist reimbursed up to $38.50 Frames – once a calendar year Up to $65 retail Reimbursed up to $44 Lens – once a calendar year Single Bi-focal Tri-focal Lenticular Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Clear/color tints & coats/ polarized $29/$33/$47 reimbursement $51/$61/$81 reimbursement $63/$75/$101 reimbursement $75/$89/$119 reimbursement Contact Lens (in lieu of lens/frame) – once a calendar year Elective Medically necessary (prior authorization is required) Up to $90 Covered 100% Reimbursed up to $90 Reimbursed up to $175
Out of Network. An out of network medical provider is one not contracted with the insured person’s policy.
Out of Network. Not covered except for emergent and urgent care as described above, and pre-arranged services while outside the area.
Out of Network. If I am not in your insurance network, the full fee is to be paid at each session at the private pay rate (listed above) and you will be responsible for filing with your insurance for possible reimbursement. If you have questions regarding your coverage, it is recommended that you contact your insurer directly. I will provide a receipt or statement as needed. Cancellations/Missed Appointments: It is important that you keep your scheduled appointments. Appointments not cancelled 24 hours in advance will be billed $100.00 Insurance does not cover these charges therefore we will not submit a claim to your insurance company. NSF/Returned Checks and Credit Card Declines: NSF/Returned checks or credit cards that are declined will be subject to a $35.00 service fee. I have read and understand the above stated information. I understand that I am financially responsible for all charges, regardless of insurance, unless otherwise written by Xxxxxx Xxxxx, LPC of Life Focus, Inc. I understand the financial policy established by Xxxxxx Xxxxx, LPC of Life Focus, Inc. Client Signature: Date: Client Name: (Please print): Patient Information (Please print clearly) Patient Name: D.O.B: Marital Status: Spouse’s Name: (if applicable) Address: City: State: Zip: Cell Phone: Work Phone: Private/personal Email: May messages be left for you at: Cell? Work? Email? Insurance Information – Please provide a copy of your insurance card (front and back), as well as a copy of your driver’s license (to prevent fraud), or bring this information to your first appointment so that copies can be made.
Out of Network. (Employee Cost) Ind. 2-Person Family Deductible $400 $800 $1,200 Coinsurance Rate 30% 30% Cost Share Max. $2,000 $4,000 $6,000 $1,000,000 Maximum
Out of Network. If you wish to visit a provider who does not participate with the plan, you’ll still be covered for designated services after meeting a deductible and paying coinsurance. Non-participating providers also may charge you for any balance above the maximum allowable amount. Cost-Sharing for Out-of-Network Services Individual deductible: $200 Family deductible: $400 (2-member family); $500 (family of 3 or more) Coinsurance: 20% after deductible, up to the cost-share maximum. Cost-share maximum: $800 individual; $1600 (2-member family); $2,000 (family of 3 or more) Lifetime maximum: In-Network: Unlimited Out-of-network: $1,000,000 per member Managed Benefits: Precertification is required for hospital admissions, certain elective surgical procedures; and other services as specified by the Plan. Members are responsible for obtaining pre-certification for the required services.
Out of Network. ATM Fees You may use your Loan Card at ATMs and cash dispensers that are not in our Network. In such cases, you might be charged a fee from such ATMs’ or cash-dispensers’ operators, networks or merchants.
