In the event of an emergency, is there someone who lives near you that we should contact?
I acknowledge that i am responsible for all charges for all services provided to me, including any amount not paid by my insuranee plan or any other plan. If my insurance plan will allow direct payment to Dr. Call, I authorize him to take assignments or any unpaid dental insurance claims. I understand that he has the right to refuse or accept assignments of dental benefits. I agree to forward him any assiged payment I receive for dental care immediately upon receipt of such payments. I also authorize the release fo all dental information necessary for processing insurance claims to my insurers or any third party of their agents.