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Patient Information

Responsible Party Information

(If Different From Patient)

If yes, please allow us to copy your card.

Thank you for entrusting your care to Monclair Dental. I authorize my insurance company to pay all benefits to Montclair Dental. Insurance may pay less than the actual charges submitted. I agree to be responsible for payment of all services rendered for myself and any dependents. I authorize Montclair Dental to release any and all clinical records and information concerning my or my dependent’s care to third-party payers and or/health professionals.