Form

I certify that I, and/or my dependent(s), have insurance coverage with   Name of Insurance Company(ies)   and assign directly to Dr.   Doctor's Name   all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Women:
Are you pregnant?   Yes   No
Due date   Date
Are you nursing?   Yes   No
Taking birth control pills?   Yes   No