ASSIGNMENT AND RELEASE I, the undersigned certify that I (or my dependent) have insurance coverage with the above the insurance company and assign directly to the doctor otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. Patient portion due at the appointment. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions
I understand I am responsible for my account balance regardless of my insurance. I also understand that my insurance is an agreement between my insurance company and myself. WP Dental will prepare and submit necessary forms to help you obtain your benefits.
I understand that I may be charged a 1% finance charge per month (12% annually) if my balance goes beyond 60 days from date of service not from date the insurance company pays my benefits. Patient portion due at appointment.
I give permission for my dentist and clinical team to take any necessary radiographs, study models, and photographs to make a complete diagnosis of my dental needs. I also give permission for my dentist and dental team to use my photographs for in-office patient education.
I consent to the use and disclosure of my protected health information to obtain payment information in connection with my dental claims.
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