I, the undersigned acknowledge that Royal Oak Smiles is not a party to the contract of my insurance. It is between myself, my employer, and the insurance company. All charges not paid by my insurance company is my responsibly regardless of non-payment. The Royal Oak Family Dentistry team will try their upmost best to confirm maximums, frequencies, limitations, waiting periods, and exclusions. But, I, understand it is ultimately my responsibility. Any unpaid balances not attached to a signed payment agreement past 90 days will result in 3rd party collections.