I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to New Image Dentistry, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the New Image Dentistry to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
All office personnel are New Image Dentistry employees, except the Doctor. The Doctor is a licensed Dentist in the State of Arizona, but is an independent contractor. The Doctor and you, without input from anyone else, will determine the Dental services and treatment to be performed on you.
I understand that the Doctor is an independent contractor at New Image Dentistry and not an employee.