I (patient, parent or guardian) authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to the patient. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for the payments of all services rendered on my behalf or dependents. I authorize Uptown Dental to immediately process any outstanding balance under $200.00 towards the credit card as indicated below. Any outstanding balances owing that are over $200.00 will be processing in monthly increments of $200.00 until balance is fully paid. I am aware I will be contacted regarding my outstanding balance and any payment not processed within 90 days, unless otherwise discussed with management, will be deemed uncollectable and forwarded to a collection agency.