I understand that I am financially responsible for all the charges incurred for orthodontic services. It is our office policy that the parent who requests services for the child and who brings the child into the office is responsible for all the fees for the services rendered.
I authorize and request that the payment be made directly to this practice for the services rendered.
I understand that I am financially responsible for all the charges, whether or not covered by my Insurance company.
I authorize the release of any information required to process the claim.
I have read the copy of Huerter Orthodontics' Notice of Privacy Practices, which are effective January 1, 2014.*