General Patient Information
Primary Dental Insurance
Secondary Dental Insurance
General Medical Insurance
ASSIGNMENT OF BENEFITS & AUTHORIZATION TO RELEASE INFORMATION
If I am entitled to benefits under any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.
I give my consent for examination and treatment.
I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.
If patient is 18 years of age or younger, please provide Parent/Guardian Signature: