Insurance Verification

  • Barry P. Setzer, D.D.S.
  • Stephen D. Cochran, D.M.D.
  • Flavio M Soares, D.D.S.
  • Karen A. Hubbard, D.D.S.

Insurance Verification

Authorization to Release Information

I authorize the release of the above provided information and any medical information necessary to: 1) provide for adequate professional coverage in the absence of the primary doctor; 2) to verify insurance coverage; and 3) to file a claim for insurance benefits related to professional services rendered.

Authorization of Assignment of Benefits

I authorize direct payment of insurance benefits from to Pediatric Dentistry for professional services rendered.

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Signature Certificate
Document name: Insurance Verification
lock iconUnique Document ID: be386eb370e1679c32935745a8f828672756b20f
Timestamp Audit
January 27, 2022 6:04 pm GMTInsurance Verification Uploaded by Christian Manuel - IP