I, the undersigned certify that I (or my dependent) have insurance coverage with {insuranceCo}, {insuranceCo67} and assign it directly to Dr. Chegini / Arsmiles Family and Cosmetic Dentistry 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 hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions