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.
The above information is necessary to provide the best care possible. I acknowledge that I have answered all questions accurately and to the best of my knowledge.
13057 W Center Rd
Omaha, Nebraska 68144
Call us: (402) 333-5337
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