INSURANCE COMPANY / DENTAL BENEFIT PLAN INFORMATION
5. Name of Policyholder /Subscriber
POLICYHOLDER / SUBSCRIBER INFORMATION (For Insurance Company Named in #3)
25. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
26. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity.
28. Number of Enclosures (00 to 99)
BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber)
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple v1s1ts) or have been completed.
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