and assign directly to Dr. Steven Kobayashi all insurance benefits, if any, otherwise payable to me for service render. 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 submissions.
I authorize the dentist to release any information, including the diagnosis and the records of any treatment or examination rendered to me or my dependent(s) during the period of such dental care to third party payers and/or other health practitioners.
I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.
I understand that my dental insurance carrier may pay less than the actual bill for my services. I agree to be responsible for payment of all services rendered on my behalf or my dependent(s).
I understand that if I do not pay the entire balance due by me within 60 days of the monthly billing date, a finance charge of 1.5% on the balance then unpaid and owed will be assessed per month (if allowed by law) and a $10 late fee each month for any overdue balances of 60 days or more. I realize that failure to keep this account current may result in you being unable to provide additional dental services except for dental emergencies or where there is prepayment for additional service. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.