I certify that I, and/or my dependents have insurance coverage as noted above, and assign directly to the dental office all insurance benefits if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance information. The dental office may use my health care information and may disclose such information for the purpose of carrying out my treatment, payment, and healthcare operations.

STATEMENT OF PRIVACY POLICY We are committed to protecting medical information about you. The details of our Privacy Policy (The Notice) will tell you about the ways in which we may use and disclose information about you. The Notice also describes your rights and outlines obligations we have regarding the use and disclosure of your information. We are required by law to make sure the medical information we have that identifies you is kept private. We Are required by law to give you a copy of our Notice of legal duties and privacy practices and to follow the terms of the Notice that is currently in effect. The Notice of our Privacy Policy can be obtained when you visit our office.