Signature On File Card

Dental Plan Name: ____________________________________________________________

I hereby accept the foregoing treatment plan and authorize release of any information that is related

to this claim. I understand the portion of the Dentist’s charges covered under the dental care plan

named above will be paid direct to the dentist. I also understand that I ‘am personally responsible

for any portions of those charges that are not covered or paid by the plan.

Employee, Patient or Parent _____________________________________________________

(Signature and Date)