Financial Policy
I understand that I am responsible for payment of services rendered by White Rose Family Dental, LLC, and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize White Rose Family Dental, LLC 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.
I affirm that the information I have given is correct to the best of my knowledge. All information herein will be held in the strictest confidence and it is my responsibility to inform White Rose Family Dental, LLC of any changes in my medical status. I authorize dental staff to perform the necessary dental services I may need, including x- rays, photographs, study models, or any aids deemed appropriate to make a thorough diagnosis of my dental needs.