Dental Assignment of Benefits Agreement

Patient Information

Name: ___________________________
Date of Birth: //____
Patient ID: _____________________

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 [DENTAL PRACTICE NAME] all insurance benefits, if any, otherwise payable to me for services rendered.

I understand that:

1. I am financially responsible for all charges whether or not paid by insurance
2. I authorize the use of my signature for all insurance submissions
3. The above-named dental practice may use my healthcare 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 payable for related services

Authorization

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered as valid as the original.

Patient/Guardian Signature: _________________________
Date: //____

Print Name: _____________________________________
Relationship to Patient: ___________________________

Office Use Only

Received by: ____________________________________
Date Processed: //____