Release of Information/Financial Responsibility/Authorization for Payment

I hereby authorize the office of

to affix my name to any and all claims or documents as related to any and all health benefits due me and my dependents through my employment with . I hereby authorize payment of orthodontic benefits payable to OoLi Orthodontics. I have reviewed the treatment plan and fees. I agree to be responsible for all charges for services and materials not paid by my benefit plan. To the extent permitted under applicable law, I authorize release of any information relating to the claim. This “Authorization” will be valid from this date. A photocopy of this document may act as an original.

Name of Patient (Parent/Guardian If Minor):

Name of Insured: