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1132 New Pointe Boulevard Unit 4 Leland, NC 28451


Thank you for choosing Michelakis Dentistry as your dental care provider. We are committed to you and your treatment being a successful relationship. 

This form is making you aware that our practice does NOT participate with any insurance and is considered out of network with all insurances.  What this means is that any estimates we give you regarding your treatment are based only on the percentages provided by your insurance, but that we are not privy to “their fee schedule” upon which those percentages are based.  We collect co-pays based on those percentages, but there is always the chance you will have a balance after the insurance has paid due to their fee schedule, not ours.

Please understand your insurance policy is a contract between you and your insurance company. We are not a party to that contract. As a courtesy to you, we happily file all claims on your behalf and handle all inquires from insurance for you as well provide certain services, including a pre-treatment estimate which we send to the insurance company at your request to more accurately estimate your portion.  Please note, that even though an insurance will offer a pre-estimate, it is never a guarantee of payment as stated on their estimates. 

It is physically impossible for us to have knowledge and keep track of every aspect of your insurance. It is up to you to contact your insurance company and inquire as to what benefits your employer/benefits liaison has purchased for you. If you have any questions concerning the pre-treatment estimate and/or fees for service, it is your responsibility to have these answered prior to treatment to minimize any confusion on your behalf. Please be aware some or perhaps all of the services provided may or may not be covered by your insurance policy. Any balance is your responsibility whether or not your insurance company pays any portion.

Understand that regardless of any insurance status, you are responsible for the balance due on your account. You are responsible for any and all professional services rendered. This includes but is not limited to: dental fees, surgical procedures, tests, office procedures, medications and also any other services not directly provided by the dentist.

By signing this form, I acknowledge that Michelakis Dentistry is an out of network provider for any insurance.

Out of Network Acknowledgement