Authorization
I hereby authorize payment to N. Dean Gregson, DMD of the group insurance benefits otherwise payable to me. I hereby authorize the doctor to release information necessary to secure the payments of benefits. I understand that I am responsible for all costs of dental treatment. I hereby authorize N. Dean Gregson, DMD to administer such medications and therapeutic procedures as may be necessary for proper dental care. The information on this form and the medical history form are correct to the best of my knowledge. I give permission to perform necessary dental work.