GETTING TO KNOW YOU Do you have family members who may
INSURANCE / DENT AL PLAN
INSURANCE / DENTAL PLAN
I certify that the information provided is accurate and will be
relied upon for granting credit and providing dental services. I
understand that I am financially responsible for the charges not
covered by or paid by my insurance for whatever reason.
By signing below, I authorize that you may verify and exchange
information on me and any additional applicants, including
requiring reports from credit reporting agencies.
I authorize payment directly to the dentist of any group
insurance benefits otherwise payable to me. I understand that I
am financially responsible for any charges not covered by this
authorization. I authorize release of any information relating
to any dental claim or claims.
I understand that this dental practice is owned and operated by
an independent dentist. I acknowledge that each dentist is
individually responsible for the dental care provided to me and
no other dentist or corporate entity is responsible for my