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.

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.