Assignment of Benefits

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Assignment of Benefits

Patient Name *

I hereby instruct and direct

Insurance Company Name *

To pay by check made out to

and mailed to

Address *

ZIP / Postal Code

To pay by check made out to {name-2} and mailed to {address-1-street_address} For dental expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my Indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner any balance of said professional service charges over and above this insurance payment. A photocopy of this Assignment Shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. I authorize doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

Signature of Policyholder

Date

PATIENT RESPONSIBILITY

Dear Patient,

You will receive services today with the understanding that in the event your coverage is not effective or Benefits are altered you will be billed and held financially responsible for the services rendered.

Patient Name *

Subscriber Name

I understand that dentistry is not an exact science and that reputable practitioners can not properly guarantee Results. I acknowledge that no guarantee or assurance has been made by anyone regarding the success of Dental treatment, which I have requested and authorized. I understand that no other dentist is responsible for my dental treatment.
I hereby authorize any dentist or dental auxiliaries of Smile Maker Dental Center to proceed with and perform the dental treatments and restorations as explained to me. I understand that this is only an estimate subject to modification due to unforeseen or undiagnosible circumstances that may arise during treatment. I understand that regardless of any dental insurance I may have I am responsible for all payments of dental fees. If the patient or the responsible party defaults in payment, Smile Maker Dental Center may exercise all rights and remedies allowed by law, including the right to hold the patient or the responsible party liable for damages, which are the Unpaid balance, collection fees, and possibly attorney fees.

I have Read the above and understand My Possible Financial Responsibility to Smile Maker Dental Center, And Hereby Affix my signature As an Acknowledgement of This Understanding.

Patient/Guardian Signature *

Date