My consent to disclosure of records shall be effective until I revoke it in writing. I authorize payment directly to the dentist of insurance benefits otherwise payable to me. I understand my dental care insurance carrier or payer of my dental benefits may pay less than the actual bill for services, and I am financially responsible for payment in-full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid by my dental care payer.
I attest to the accuracy of the information on this page