OoLi Orthodontics

Authorization For Signature On File


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:

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Signature Certificate
Document name: Authorization For Signature On File
lock iconUnique Document ID: 6ca8fb099ecb8f6fccbdac36e9ec43e0b1c6ff98
Timestamp Audit
June 30, 2020 5:40 am MSTAuthorization For Signature On File Uploaded by Won-Woo Jonathan Park - forms@ooliortho.com IP 104.28.85.158
April 2, 2023 11:08 am MSTOoLi Team - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141
April 2, 2023 11:08 am MSTMJ Cindy Kim - cindy@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141