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Page 1: r › tpn › c › C1288 › docs › ... · treatment authorization and ack040wledgement I authorize release of any information concerning dental treatment to my benefits provider
Page 2: r › tpn › c › C1288 › docs › ... · treatment authorization and ack040wledgement I authorize release of any information concerning dental treatment to my benefits provider
DaniLynne
Text Box
Check Yes or No
DaniLynne
Text Box
Check Yes or No
DaniLynne
Text Box
Check any of the following which you've had or are currently being treated for: