ASSIGNMENT OF INSURANCE BENEFITS
CONSENT FOR EVALUATION
I was given the opportunity to read the Privacy Notice and object to disclosures of my protected health information.
I authorize that I am financially responsible for all charges whether or not paid by insurance.
I authori ze my insurance company to pay to the dentist all insurance benefits otherwise payable to me for services rendered. l authorize the use of this signature
all insurance submissions.
I authorize the dentist to release all information concerning my health care, advice and treatment provided for the purpose of evaluating and administering claims
for insurance benefits.
I permit a copy of this authorization to be used in place of the original.
Patient's Signature or (Parent's if minor)
Use your mouse cursor or the tip of your finger to sign below