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    Assignment and Release

    I, the undersigned certify that I (or my dependant) have insurance coverage with above mentioned insurance company and assign directly to Dr.Julio A. Rodriguez 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 hereby authorize the doctor to release all information necessary to secure the payment of benefits, I authorize the use of this signature on all insurance submissions.

    Dental History (Confidential)

    Please Check the Radio Button if you had problems with any of the following:

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    List any medications you are currently taking:

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    Patient Acknowledgement of Receipt of the Notice of Privacy Practices

    I acknowledge that i was provided with a copy of the Notices of privacy Practices, describing how my health information may be used or disclosed under the federal law. I hereby consent to the use and disclosure of my health information for the purpose and the activities under the federal privacy law. Iam aware that the Notice may be changed at any time I may obtain a revised copy by calling the offices