Minor Child - May need to complete both blocks for parent information adults - Complete primary insured dual coverage? also complete secondary insured
PRIMARY INSURED
IF NO INSURANCE COMPLETE FOR RESPONSIBLE PARTY
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SECONDARY INSURED
I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental / medical histories and other information about my dental treatment to third party payors and /or other health professionals.
In the case of default of payment, I promise to pay any legal interest on the balance due, to together with any collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts.
To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medicines change. I shall inform the dentist and staff at the next appointment without fail
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