INSURANCE INFORMATION Insurance Authorization 1.        I authorize the release of information to my insurance carrier. 2.        I authorize payment directly to my dentist. Employee Name (please print)________________________ Employee SS#_______________ Employee’s DOB______________ Employer’s Name________________________ Insurance Company______________________ Mailing Address for Insurance_________________________ Insurance Company Phone #_________________________ Group or Plan#___________________ In a spirit of mutual respect, we assert that the contract of insurance is between the insured (you) and the insurance company. We are the provider of healthcare. Your insurance company has no specific obligation to us, or we to them. The personnel director at your place of employment and/or insurance company has issued you a booklet that has defined your individual coverage more specifically than we could ever know.  Any assistance we provide should be constructed as a courtesy, not an acceptance of responsibility. There is no standardization in the insurance industry; therefore, we cannot be expected to know all of their idiosyncrasies. We ESTIMATE what your insurance will pay and ask that you pay the estimated portion at the time of your appointment. After insurance pays, you may or may not receive a bill or a check from us depending on what they actually pay. If this is agreeable with you, please sign below. Signature________________________________Date____________