Dr. Sung and Associates

Patient Information:

First Name:

Last Name:

Middle Name:

DOB:

Phone:

Email:

Acknowledgement of receipt of notice of privacy practices

I, have received a copy of this office’s notice of Privacy Practices.

Patient or Guardian Signature

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Date:

AUTHORIZATION TO RELEASE INFORMATION & Payment AGREEMENT

I, authorize the dental insurance company. I provide to release benefit and/or claim information to Dr. Sung and associates. This consent is effective until such date as I can cancel this consent in writing. I understand that information obtained as a result of this consent may be used after the cancellation date. This information will be used only for the purpose it is intended. I understand that I am responsible for payments required by insurance or that insurance does not cover or I do not have dental insurance.

Patient or Guardian Signature

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Date: