Assignment and ReleaseAssignment and Release • February 3rd, 2016
Contract Type FiledFebruary 3rd, 2016I, the undersigned, have insurance with and assign directly to Palm Valley Family Dentistry, P.A. 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 within 30 days from the date of service. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.