Unformatted text preview: rance Company: (______) _______________
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.
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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- Fall '11
- Dentistry, Following, personal representative, Oral hygiene