I authorize Dr. Harmer/Dr. Rumack to perform the necessary dental treatment my child may need for his or her well-being. I authorize Dr. Harmer/Dr. Rumack to release any information, including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payers (i.e. insurance company) and/or health practitioners (i.e. you child's physician or orthodontist).
I request that my insurance company pay directly to Dr. Harmer/Dr. Rumack, and I understand that my insurance carrier may pay less than the actual bill for service; therefore, I agree to be responsible for the payment of all services rendered on my child's behalf. I authorize the use of this signature on all my insurance submissions.