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P.O. Box 31224, Tampa, FL. 33631
Address to send Dental Claims: ________________________________________________________________________________________
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.
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.
- Fall '11