Common Contracts
1 similar Assignment and Release contracts
ASSIGNMENT AND RELEASEAssignment and Release • November 5th, 2019
I, the understated, have insurance and assign directly to Iowa Wisdom Teeth 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.
