I certify that I, and/or my dependent(s), have insurance coverage with the aforementioned Insurance Company(ies) and assign directly to Dr. Jai H. Shin, DDS, PLLC all insurance benefits, if any, otherwise payable to me for services rendered. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my health care information and may disclose such information to the to the aforementioned Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end and when my current treatment plan is completed or one year from the date signed below.
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