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Insurance Authorization Form

Vitta Dental

80 Park Avenue Suite 1A,
New York, NY 10016
(518) 254-6451

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Insurance Authorization Form( * mandatory to fill )

Please read and find this statement so we can notify your insurance company that we have assignment (payment) directly from them. on your behalf, for services we render.

I hereby authorize my insurance company to make payment directly to Arlington Dental Group P.C. for dental service provided.

I understand that payment is required at the time of treatment for the estimated non covered portion of the dental fee.

I further understand that the insurance company will not guarantee the accuracy of the estimates benefits due to me before treatment is rendered. I, therefore, understand that the Arlington Dental Group P.C. cannot be held responsible if the estimate of coverage made at the time of treatment is different from the actual coverage. Upon payment the insurance company, if there is a balance due, I understand that the balance must be paid. If payment received results in a credit balance, a refund check will be issued.

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