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I hereby assign my benefits payable from this claim to the named dentist and authorize payment directly to him/her. A T Address D E N T I S T Apt. I E City N Prov. Postal Code T Duplicate Form Signature of Subscriber Phone No.: For Dentist s Use Only - For additional information, diagnosis, procedures, or special consideration. I understand that the fees listed in this claim may not be covered by or may exceed my plan benefits. I understand that I am financially responsible to.

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