I, the undersigned certify that I (or my dependent) have insurence coverage with                                  and assign directly to Estero Dental Care  all insurance benefits, if any, otherwise payable to me for services rendered. I understand taht I am financially rsposible for all charges whether or not paid my insurance. I herby authorized teh doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.