I authorize release to my dental benefits plan administrator and the ADA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

I authorize my insurance company to make payment directly to this dental provider.

As you may know your insurance covers only a percentage of the total fee of services provided and we therefore require a credit card number to accept assignment from your insurance carrier. This is with the understanding that our office will be calling you for authorization to use this credit card to pay the difference not paid by your insurance provider.

I understand that anything not covered by my dental insurance is my full responsibility to pay. Our office will help to provide the most accurate estimate possible, but it is ultimately the patients responsibility to know what their insurance coverage details are.