Assignment of Benefits Agreement for Orthodontic Treatment

Patient Information

Name: ____________________________ Date of Birth: _____________________ Account Number: ___________________

Insurance Information

Primary Insurance: ________________ Policy Number: ___________________ Group Number: ____________________

Agreement Terms

I, the undersigned, certify that I (or my dependent) have insurance coverage with the above-named insurance company and assign directly to Dr. _________________ all insurance benefits, if any, otherwise payable to me for services rendered.

Authorization Statements

1. I hereby authorize the orthodontist to release all information necessary to secure the payment of benefits.
2. I authorize the use of this signature on all insurance submissions.
3. I understand that I am financially responsible for all charges whether or not paid by insurance.
4. I authorize the payment of dental benefits to the orthodontist for services provided.

Payment Terms

• This assignment will remain in effect until revoked by me in writing.
• A photocopy of this assignment is to be considered as valid as the original.
• I understand that I am responsible for paying any deductibles, co-payments, or non-covered services.

Signatures

Patient/Guardian Signature: ___________________ Date: __________

Witness: __________________________________ Date: __________

Office Use Only

Received by: ____________________________ Date Processed: _________________________