Insurance Information

I agree to have my signature considered to be “on file” for purposes of insurance form processing. I also agree to be responsible for payment for any service or portion of service not covered by insurance. I authorize release of necessary information relating to the processing of dental insurance forms. In order for us to process your insurance forms more rapidly and to assist you in getting all the benefits to which you are entitled, please sign and date below. I request that all dental benefits, if any or other amounts otherwise payable to me or on my behalf for services rendered, be paid directly to the provider of service. I understand that I am financially responsible for all charges for services performed by the provider. If insurance proceeds are insufficient to cover my obligations for services rendered, I am liable for the shortfall. I authorize the provider of service to release all information necessary to secure the payment of benefits. I also consent to the examination and/or treatment of myself and all minor children listed by doctor’s assistants and other medical personnel. Failure to provide complete information may result in my receiving a bill of services.