Common Contracts
1 similar Assignment and Release, Financial Agreement contracts
Assignment and ReleaseAssignment and Release, Financial Agreement • February 3rd, 2016
I, 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.
