I understand that Mcllwain Family Dentistry is not a contracted provider for my insuarance company and that MFD will be filing to my insurance company as a courtesy and expect their payment on 30 days. I recognize that it is my responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by the insurance company.
I hereby assign all dental and/or surgical benefits, to include major medical benefits to which I am entitled, including private insurance and other health plans to: McIlwain Family Dentistry, Inc. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorise said assigns to release all information necessary to secure the payment.