Authorization to receive payment for services and to release or receive written/verbal information.
It is necessary to obtain payment for our services from second or third party payers. In order to provide dental treatment and to receive payment for our services it is necessary to exchange information with your insurance company. It may also be necessary to send or receive information from other professionals or agencies in the course of your dental treatment Any information received will become part of your clinical record. Information received from other sources cannot be released by the office.
*Before we exchange information we need your written authorization
I hereby authorize this office to send or receive the information checked below.
I have been informed that I may revoke this permission at anytime by writing to the office Consequently, I understand that if revoked, Dr. Yelk will no longer continue to provide dental treatment.
I have read and understand the content of this document and understand that a fax copy or a photo copy shall be considered as the original.
Circle the relationship to below and sign
Signature of Patient / Parent / Guardian