Patient Release Form

Patient Release Form
Authorization to Release Information

I hereby authorize the above-named Orthodontist(s) to provide an insurance company, claim administrator(s), and consuming health care professionals, information concerning dental care, advice, treatment, or supplies provided. This information will be used exclusively for the purpose of evaluating and administering claims for benefits.
Patient/Authorized Guardian's Signature
Date

MonthDayYear
Date
Authorization to Pay Benefits to Orthodontist

I hereby authorize payment directly to the above-named Orthodontist(s) of the Dental Benefits otherwise payable to me.
Patient/Authorized Guardian's Signature
Date

MonthDayYear
Date
Should be Empty: