Authorization and Release
I certify that I have read and understand the above infomation to the best of my knowledge. The above questions have been accuratly answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any infomation including the diagnosis and the records of any treatmet or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practioners. I authorize and request my insurance company to pay directly to the dentist od dental group insurance benefits otherwise payable to me to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
