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Patient Information











Billing Information - Person responsible for this account?




What is the responsible party's relationship to the patient?

Does patient, if a minor, reside with this person?


Whom can we thank for referring you to our office?

Dental Insurance



(if different from patient's address)
Is patient covered by an additional Dental plan?


(if different from patient's address)


Medical Insurance



(if different from patient's address)
Is patient covered by an additional Medical plan?


(if different from patient's address)

Assignment and Release

The above information is true to the best of my knowledge. I authorize my insurance benefits to the be paid directly to the provider, Riley J. Hicks D.D.S. I understand that I am financially responsible for all charges whether or not paid by insurance.

The above named doctor may use my health care information and may disclose such information to the above named insurance comapny(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date entered here.




 
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