Endodontic Treatment Assignment of Benefits Agreement

I, _________________________ (Patient Name), hereby authorize and direct my insurance carrier(s) to pay directly to:

Practice Name: ______________________ Provider Name: _____________________ Address: ___________________________ Tax ID/NPI: ________________________

Insurance Benefits Assignment

I authorize the payment of dental benefits otherwise payable to me directly to the above-identified provider. This Assignment of Benefits applies to all insurance or other third-party benefits available for healthcare services provided by this dental practice.

Financial Responsibility

• I understand that I am financially responsible for all charges, whether or not paid by insurance
• I acknowledge that benefit quotes provided by my insurance company are not a guarantee of payment
• I agree to pay any co-payments, deductibles, or non-covered services at the time of treatment

Authorization for Release of Information

I authorize the release of any dental or medical information necessary to:

• Process insurance claims
• Determine benefits
• Secure payment for services rendered

Duration and Revocation

This Assignment of Benefits shall remain in effect until revoked by me in writing.

Patient Signature: ___________________ Date: ___________

Witness: ___________________________ Date: ___________

Insurance Information: Primary Carrier: _____________________ Policy Number: ______________________ Group Number: ______________________

A copy of this assignment is considered as valid as the original