Oral Surgery Assignment of Benefits Agreement

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Insurance Information

Primary Insurance: ______________ Policy #: _________________ Subscriber Name: _______________ Group #: _________________

Authorization and Agreement

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.

Terms and Conditions

1. I understand that I am financially responsible for all charges whether or not paid by insurance.
2. I authorize the use of my signature on all insurance submissions.
3. I authorize the release of all information necessary to secure payment of benefits.
4. I authorize the dentist to release all information necessary to secure the payment of benefits.
5. I understand that this authorization will remain in effect until revoked by me in writing.

Financial Agreement

• I acknowledge that payment is due at the time of treatment unless other arrangements are made.
• I agree to pay all related fees, less initial insurance benefit coverage.
• I understand that a fee of $_____ will be charged for missed appointments without 24-hour notice.

Signatures

Patient/Guardian Signature: _________________ Date: __________

Print Name: ______________________________ Relationship: _____

Witness: _________________________________ Date: __________