Dentistry On Bleams 
Dentistry That Cares For Your Smile
AUTHORISATION CONSENT
I authorize the release of my benefits plan to the Dental Administrator and CDA,
and the information contained in claims submitted electronically. I also authorize
the communication of information related to the coverage of services described
to Dr. Chhavi Saxena and Associates.
This authorization shall continue in effect until the undersigned revokes the same.