To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. * I certify that I, and/or my dependent(s), have insurance coverage with * Please Select HMO PPO MEDICARE MEDI CAL OTHERS
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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 submission The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Companies And their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable fore related Services. This consent will end when the current treatment plan is completed or one year from the date signed below. * Payment is due in full at time of treatment unless prior arrangements have been approved. * PLEASE TYPE OR ENTER NAME of Patient, Parent, Guardian or Personal Representative *
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