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address to send dental claims

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Unformatted text preview: rance Company: (______) _______________ 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: 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: 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 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 ___________________________________________________________________ ____________________________ Please print name of Parent, Guardian or Personal Representative Date PLEASE COMPLETE...
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