Dental Claim Form
To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim. X _____ Patient/Guardian Signature Date 38. Place of Treatment n(e.g. 11 ... Oral & Maxillofacial Surgery 1223S0112X
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Electronic Funds Transfer (EFT) / Direct Deposit Agent’s ...
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