A Smile 4 U - Logan Honeycutt

O box 31224 tampa fl 33631 address to send dental

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Unformatted text preview: _______ P.O. Box 31224, Tampa, FL. 33631 Address to send Dental Claims: ________________________________________________________________________________________ AUTHORIZATION I understand that the information is correct to the best of my knowledge. I understand it will be held in the strictest of confidence and it is my responsibility to. I inform this office of changes in medical status. Child Consent: Logan Tyler Honeycutt I am the parent, guardian, or personal representative of ________________________________. And there are no court orders now in effect that prohibits me from signing this consent. I do hereby request and authorize the dental staff to perform necessary dental services for the child named above. Insurance Assignment and Release: Medicaid / Wellcare I certify that my dependent(s) is covered by insurance with ______________________________. And assign directly to A Smile 4U all insurance benefits. I understand that I am financially responsible for all charges whether or not paid by...
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This note was uploaded on 01/28/2014 for the course ITMG 321 taught by Professor Krueller during the Fall '11 term at American Public University.

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