Patient Information
M F

Married
Widowed
Single
Minor
Separated
Divorced
Partnered for
Dental Insurance - Primary
Yes No

Dental Insurance - Secondary
Yes No

ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Dr. Edward P. Laco all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.