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Home » Individual Forms
 
Item Name: Signature on File
Product Number: T250SF
Price: $14.99/ea
Qty: 
Description: This form gives you authorization from the patient to release information to the insurance carrier and request that they in turn make direct payment to your office. Tablets of 100 single-sided sheets, pre-punched and cut to fit.


 
Signature on File


Note All forms and charts can be customized to meet your specific requirements. Please call 800-243-4675 for more information.

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Wisconsin Dental Association, 6737 West Washington Street, Suite 2360, West Allis, WI 53214
(414) 276-3954 • (800) 243-4675