Dental Attraction Center
Dental Attraction
4727 Frankford Rd Ste 333
Dallas, TX 75287
972-733-0999
Date ________________
Patient
_______________________________________________________________
Employer
_____________________________________________________________
Claim Group
__________________________________________________________
SSN / Group
__________________________________________________________
I hereby instruct and direct my insurance company to pay by check
made out and mailed to:
Dental Attraction Center
4727 Frankford Rd, Ste 333
Dallas, TX 75287 |
OR |
Dental Attraction Center of Plano
7224 Independence Pkwy, Ste 312
Dallas, TX 75287 |
If my current policy prohibits direct payment to doctor, I hereby
also instruct and direct you to make out the check to me and mail it as
follows:
Dental Attraction Center
4727 Frankford Rd, Ste 333
Dallas, TX 75287 |
OR |
Dental Attraction Center of Plano
7224 Independence Pkwy, Ste 312
Dallas, TX 75287 |
For the professional or medical expense benefits allowable, and
otherwise payable to me under my current insurance policy as payment
toward the total charges for the professional services rendered. THIS
IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.
This payment will not exceed my indebtedness to the above-mentioned
assignee, and I have agreed to pay, in a current manner, and balance of
said professional service charges over and above this insurance payment.
A photocopy of this Assignment shall be considered as effective and
valid as the original.
I also authorize the release of any information pertinent to my case
to any insurance company, adjuster, or attorney involved in this case.
I authorize doctor to initiate a complaint to the Insurance
Commissioner for any reason on my behalf.
Dated this ____________day of _____________________, 20____________
___________________________________________
______________________________________________
Signature of Policyholder Witness
Signature of Claimant, if other then policyholder.