1. I hereby authorize Howard Y.B. Kim DDS, Inc. to perform any and all dental treatment and to use such methods, drugs and agents as seen advisable. This authorization shall remain in effect until cancelled.
2. I hereby assume any and all financial responsibility for said child and hereby assign payment of all dental care insurance benefits to Howard Y.B. Kim DDS, Inc. and assume responsibility for fees not covered by my group insurance.
3. I hereby authorize Howard Y.B. Kim DDS, Inc. to provide any insurance company(s), claim administrators, and consulting health care professionals with information concerning health care, advice, treatment, or supplies provided. This information will be used exclusively for the purpose of evaluating and administering claims for benefits.
Use your mouse cursor or the tip of your finger to sign below