I authorize my insurance company to pay to Logan Peak Dental all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submission. I authorize Logan Peak Dental to release all information necessary to secure payment of benefits. I understand that Logan Peak Dental cannot render services on the assumption that any of the charges will be paid by an insurance company. I understand that I am financially responsible for all charges whether paid by my insurance or not. I understand that if I do not pay my bill collection action will be taken and I will be responsible for paying any collection and attorney fees.