Unformatted text preview: insurance. I authorize the use of my
signature on all insurance submissions.
A Smile 4U may use my child’s health care information and may disclose such information to the above-named insurance company and their
agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Signature of Parent, Guardian or Personal Representative ___________________________
Date Rebekah Naomi Diaz
___________________________________________________________________ ____________________________ Please print name of Parent, Guardian or Personal Representative Date
PLEASE COMPLETE BOTH SIDES...
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- Fall '11