I request that all dental benefits, if any, or other amounts which may payable to me or on my behalf for services rendered to my child, be paid directly to Healthy Smiles for Kids of Orange County (“HSK”), the provider of services. I authorize HSK to release all information necessary to secure payment of benefits. I also authorize and consent to the dental examination and/or treatment of my child. I am aware that by signing below I certify that all information on this form is complete and correct. HSK may verify this information from whatever sources it deems necessary and may provide others with this information to the extent permitted by law. By signing this document, I acknowledge that I have received a copy of Healthy Smiles for Kids of Orange County Patient Bill of Rights and Responsibilities by clicking here