Common Contracts
2 similar Assignment and Release contracts
ASSIGNMENT AND RELEASEAssignment and Release • June 3rd, 2021
I, the understated, have insurance and assign directly to Story City Dental all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits.
ASSIGNMENT AND RELEASEAssignment and Release • April 13th, 2017
I, the understated, have insurance and assign directly to Story City Dental all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits.
