Consent For Use And Disclosure Of Health Information - The Rector Dental Group Page 3

SIGNATURE ON FILE

Patient's Name: ________________________________________________________________

Last

First

Middle Initial

I hereby authorize payment of the dental benefits otherwise payable directly to The Rector Dental

Group.

__________________________________________________________________

Signature (Insured Person)

Date

The Rector Dental Group is authorized to provide pertinent information to those persons requiring it for

the use of evaluating and administrating claims for benefits.

I authorize the use of this form on all of my insurance submissions.

I permit a copy of this authorization to be used in place of the original.

I understand that I am responsible for my bill.

___________________________________________________________________

Parent, Legal Guardian or Authorized Person's Signature

Date

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Parent category: Medical