Periodontal Treatment Assignment of Benefits Form

I, _________________________________ (Patient Name), authorize and direct my insurance carrier to pay benefits directly to:

[Practice Name] [Address] [City, State ZIP] [Phone Number]

Insurance Authorization

• I hereby authorize the release of any dental/medical information necessary to process insurance claims related to my periodontal treatment.
• I authorize direct payment of dental benefits to the practice listed above for all services rendered.
• I understand that I am financially responsible for all charges, whether paid by insurance or not.

Financial Agreement

1. I acknowledge that payment is due at the time of treatment unless prior arrangements have been made.
2. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child.
3. I understand that any insurance estimate given is not a guarantee of actual insurance payment.
4. I understand that I am responsible for any balance after insurance pays its portion.

Acknowledgment

I have read and understand this assignment of benefits agreement. I understand that I am responsible for all costs of periodontal treatment.

Patient Signature: _________________________ Date: //___

Witness: _________________________________ Date: //___

This document is valid for all present and future periodontal treatment until revoked in writing.