Insurance Authorization
Please read and sign before treatment can be performed. I authorize the dentist to release my information including diagnosis and the records of my treatment or examination rendered to me and/or other health practitioners; I hereby assign all medical, dental, and/or surgical benefits to which I am entitled for this service to Friendly Smiles Dental Care. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that my dental insurance carrier may pay less than the actual bill for services, and in that event, I am financially responsible for all remaining balance of and/or dependents account within 60 days.