I authorize release to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

The undersigned affirm that the information given in this questionnaire is true and accurate to the best of my/our knowledge. I/We authorize the dental staff to perform such dental services as may be necessary and authorize the release of written records to and referring or treating dentist, physician, medical facility or insurance company for legal documentation.

I/We accept full responsibility for all charges for treatment to the patient regardless of insurance coverage.