(All insurance companies require an ID # which 95% of the time is your social security number. Your claim will not be processed if blank.)
I, the undersigned certify that I (or my dependent) have insurance coverage with the above and assign directly to Boston Endodontics 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.
We provide a completed root canal with a temporary filling only. The permanent restoration (Filling, Crown or Cap) will be
completed by your general dentist. We advise that you contact your dentist as soon as possible.
The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any
member of his/her staff responsible for any errors or omissions that I may have made in the completion of this
5 Longfellow Place, Suite #205
Boston, MA 02114
50 Salem Street, Building A
Lynnfield, MA 01940