"I authorize release; to my dental benefits plan administrator and the CDA, information contained in claims submitted
electronically. I also authorize the communication of information related to the coverage of services described to the
named dentist. This authorization shall continue in effect until the undersigned revokes the same.
I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history, and I have
not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any
questions regarding my medical-dental history. I authorize the dentists to perform previously discussed diagnostic
procedures and treatment as may be necessary for dental care. I also understand that consultation with my medical
doctor may be required, and I consent my physician being contacted if necessary. I understand that responsibility for
payment for dental services provided for myself or my dependants is mine, and I will assume responsibility for fees
associated with these services.