I, the undersigned, authorize and request Pediatric Dental Associates of Manhattan to charge my credit card, indicated above, for balances due for services rendered that my insurance company identifies as my financial responsibilities. This authorization relates to all payments not covered by my insurance company for services provided to me by Pediatric Dental Associates of Manhattan.
I understand that the information that I have given is correct to the best of my knowledge, that it will be in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.
I understand that I am financially responsible for payment of services rendered. I am also responsible for paying any co-payment and deductible that my insurance does not cover if applicable. I hereby authorize the dentist to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions, whether manual or electronic.
