RESPONSIBLE PARTY INFORMATION (unless same as above)
DENTAL INSURANCE INFORMATION
By signing this form, I/we authorize the release of information regarding this claim to my insurance carrier or hospitals or other doctors who have treated the patient. I further assign payment directly to this office by signing this form. I acknowledge that I am responsible for all monies due this office not paid by insurance, for the services rendered as described in this/these claim(s). I agree to the office payment/insurance policy. A service charge of 1 1/2 % will be charged on all accounts after 60 days. There is a $25.00 returned check fee.
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