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Ordinarily, payment is due in full at the time of treatment. However, as a courtesy we will accept assignment of insurance benefits when a credit card authorization is provided to handle any balances that are left after insurance payment is received, or that remain unpaid 90 days after claims submission.
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ASSIGNMENT OF BENEFITS OPTION
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signature required here in order to submit insurance claims on your behalf
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I hereby authorize the release of all information necessary to secure payment of insurance benefits.
I authorize the use of the signature below on all insurance submissions.
I understand that I am financially responsible for all charges not paid to the dentist by my insurance carrier.
Without my signature insurance claims cannot be submitted on my behalf.
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[nameF]
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Birthdate:
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[Birthdate]
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Date: [dateToday]
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INSURANCE AUTHORIZATION
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Last Name:
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[nameL]
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First Name:
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signature required here to have insurance benefits assigned to the doctor
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I authorize payment to Robert M Hersh DMD of the insurance benefits otherwise payable to me.
I will leave my credit card on file and my signature below authorizes this office to charge to my credit card all balances not paid by my insurance carrier within 90 days of claims submission.
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CREDIT CARD INFORMATION (required for Assignment of Benefits)
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Card Type
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;Choose one|American Express|DiscoverCard|Mastercard|Visa
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<------ ENTER THE LAST 4 DIGITS OF YOUR CREDIT CARD.
Provide your card to the receptionist. The full card number will be keyed into our secure merchant software, where it will be stored encrypted for security.
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Billing address ZIP CODE
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Cardholder's name (as shown on card)
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/
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Expiration date: MM/YY
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Billing address the card is registered to.
If it is a business card, this may be the business address.
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