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Retainers in the Military

Release of Information/Financial Responsibility/Authorization for Payment

I hereby authorize the office of

OoLi Orthodontics – Tempe

OoLi Orthodontics – Phoenix

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:

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Your legal name

Your email address

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Timestamp

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February 8, 2024 3:52 pm MST

Retainers in the Military Uploaded by Won-Woo Jonathan Park - forms@ooliortho.com IP 68.104.180.82