INSURANCE ASSIGNMENT AND RELEASE – I, the undersigned assign directly to KING ORTHODONTICS all insurance benefits, otherwise payable to me for services rendered.
I also hereby authorize KING ORTHODONTICS to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all insurance submissions.
FINANCIAL RESPONSIBILITY – I understand that I am financially responsible for all charges whether or not paid by insurance. I am aware of the financial policies regarding patient services, payment and insurance assignment if applicable.
In accordance with the federal government HIPAA rules, please sign below to acknowledge you have received our Notice of Privacy Practices; it will in no way affect the care you receive at King Orthodontics.