AUTHORIZATION FOR RELEASE OF INFORMATION: (All patients/guarantors must sign) I certify that the above information is correct. I authorize release of any information relating to my dental claims. I understand that I am responsible for all costs of dental treatment, I hereby authorize payment of the group insurance benefits otherwise payable to me directly to Loomis Family Dental.
PERMISSION FOR TREATMENT: (All patients/guarantors must sign) I hereby give my permission to Loomis Family Dental dentists to provide dental treatment as deemed necessary.
PAYMENT AGREEMENT: (All patients/guarantors must sign) I understand that my Insurance Policy is between the insurance company and myself and I am liable to Loomis Family Dental for services rendered. I also understand I will be furnished with an estimate regarding my insurance benefits at the onset of treatment. I agree to pay Loomis Family Dental for all dental treatment at the time of service. I promise to pay my account until my balance has been paid in full. Should my account become past due, I will be charged 1.5% per month interest with $25.00 late charge fee on the overdue amount. I also understand that should my account become delinquent, it may be turned over for collection, including any attorney’s fees incurred.