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(unless prior arrangements have been approved) If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover. I hereby authorize payment directly to Dr. Sue VanBlaricum of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
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Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.
412 College St. Lafayette, TN 37083 Phone: 615-666-6155 www.lafayettefamilydentistry.comwww.lafayettefamilydentistry.com
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