Common use of Out of Network Clause in Contracts

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. 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 bill 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. If my treating dentist provider 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 provider is participating provider, I will be responsible for any deductibles, co- co-payments, the costs of uncovered services and any other part of the xxxx bill that my dental health 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 21% monthly on all balances that have been outstanding for thirty (30) days or more. Should we receive a bounced check back, due to non-sufficient funds, the practice is permitted to charge you a returned-check fee between $20-$40, or a percentage of the check amount. GUARANTOR If you are signing this consent as a guarantor you are accepting financial responsibility to pay for the patient's bill, which will be mailed to your home address. If the patient is a child, the responsible party is the guarantor whom the child primarily lives with. The practice does not take responsibility for handling custody agreements or divorce decree's when it comes to financial responsibility. RELEASE OF INSURANCE BENEFITS I agree to be responsible for all charges for dental services and materials not paid by my dental health benefit plan, unless prohibited by law or the treating dentists or dental practice provider 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 Dubuque Orthopaedic Surgeons, PC'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 affiliatesDubuque Orthopaedic Surgeons, PC. 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 ACKNOLEDGE THAT I MAY REVOKE MY CONSENT TO ALL OR ANY PART OF THIS CONSENT CONONSENT AGREEMENT AT ANY TIME BY DOING SO IN WRITING. _ PATIENT NAME (PRINTED) DATE _ (PRINT, SIGN AND RETURN TO OFFICE OR CLICK THE BOX TO CREATE AND ADD A DIGITAL SIGNATURE) SIGNATURE OF PATIENT/LEGAL RESPRESENTATIVE _ DATE GUARANTOR NAME (PRINTED) YES NO I would like to receive a copy of this consent, please select one. 2020/12 General Consent Agreement – Dubuque Orthopaedic Surgeons, PC RELATIONSHIP TO PATIENT

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 bill 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. 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_