I certify that I, and/or my dependent(s) have insurance coverage with the above company and assign Dyker Dental Services all 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 authorize the use of my signature on all insurance submissions. Dyker Dental Services may use my health care information and may disclose such information to the above-named insurance company and their agents.