Authorization and Release
I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me, my spouse or my child during the period of such dental care to the third party and/or other health practitioners.
I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.
I understand that my dental insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.