By submitting this form you realize that submissions may not be protected by the Health Insurance Portability and Accountability Act (HIPAA) and associated regulations. For HIPAA compliance please download the form and print it before coming into the office.
I, understand, certify that I (or my dependent) have insurance coverage and assign directly to Drs. Bishara-Margolian DPC 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 Drs. Bishara –Margolian to release all information necessar
to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
* All fees or balances not covered by your dental insurance policy will be payable at time of visit. You must provide us with all
insurance information. We do not have access to your private insurance policy information unless provided to us.
I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge
and have not knowingly omitted any information. If required, I consent to my physician being contacted regarding any specific medical
questions. I authorize Drs. Bishara-Margolian and their staff to perform necessary diagnostic procedures and treatment as required to
achieve a proper level of dental care.
2378 Highway #2 (Home Depot Plaza), Bowmanville, Ontario, L1C 3K7, Canada