|
|
|
(Signature on File) Patient Name: (Last)___________________________(First)__________________________(M.I.)_______ It is your responsibility to familiarize yourself with your insurance plan. The insurance company you are insured with determines the amount of coverage provided by your policy. Our office can only estimate the amount of coverage based on the information provided to us by you or your insurance company. We cannot guarantee any amount of coverage and it is ultimately your responsibility if your insurance company does not cover your claims. Our office is more than happy to bill your insurance company for you. After 60 days from the time your claim is submitted, if we have not received payment from them, we must ask you to pay your account in full. However, should we receive an insurance payment after that time period, you will be reimbursed for the amount the insurance company sends to us. Endre Selmeczy, D.M.D. is authorized to provide any insurance company(s) claim, administration(s) and consulting health care professional(s), information concerning health care advise, treatment and supplies provided. This information will be used for the purpose of evaluating and administrating claims for benefits. This authorization is valid for the term of coverage of the policy or contract, in force on this date only, or for five years, which ever is shorter. I know I have a right to receive a copy of this authorization upon request and agree that a photographic copy of this authorization is as valid as the original.
I have read and understand the foregoing statement and hereby authorize payment directly to Endre Selmeczy, D.M.D. of the dental benefits otherwise payable to me.
| |
| _________________________________________ | _________________ |
| Signature (Insured Person) | Date |