To avoid misunderstanding regarding insurance, we wish our patients to know that ALL PROFESSONAL SERVICES RENDERED ARE CHARGED DIRECTLY TO THE PATIENT and that PATIENTS ARE PERSONALLY RESPONSIBLE FOR PAYMENT OF FEES. We will prepare necessary forms or reports to help you to obtain your benefits from insurance companies. We do not render our services or the basis that insurance companies will pay all our fees. Each fee is individual for the individual patient. There will be an additional fee for letter or reports.

ASSIGNMENT AND RELEASE: I hereby authorize my insurance benefits to be payable directly to the undersigned dentist and I am financially responsible for non-covered services. I also authorize the doctor to release any information requested.

I authorize treatment of the above named person and agree to pay all fees charged for such treatment. I agree to pay all charge for members of my family and myself, shown by statements, promptly upon presentment thereof, unless credit arrangements are agreed upon in writing.