I certify that I, and/or my dependent(s) have dental insurance coverage with the above mentioned dental company and assign directly to Bilius Family Dentistry DBA Ridgefield Dental Arts 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/dental office may use my health care inforamtion 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.  

 I fully understand that I am required to give 24 hours advanced notice if I need to cancel or reschedule a dental appointment.  Failure to do so will result in a non-refundable $50 cancellation fee charge.