Please fill out the form below. Once you click the Submit button, it will send an email with your answers to our office.
Last Name / First Name / Middle Initial
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with
and assign directly to
all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services. This consent will end when my current treatment plan is completed or one year from the date signed below.
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
Place a mark on "yes" or "no" to indicate if you have had any of the following: