OoLi Orthodontics

Retainers in the Military

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):

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Signature Certificate
Document name: Retainers in the Military
lock iconUnique Document ID: 0c1dd50ef3bccc48c700c4f142a1ab2df61cdbde
Timestamp Audit
February 8, 2024 3:52 pm MSTRetainers in the Military Uploaded by Won-Woo Jonathan Park - forms@ooliortho.com IP