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SURNAME This form is the approved form as prescribed under section 12 2 of the Dental Benefits Act 2008 DESCRIPTION OF SERVICE optional DB2-DB BENEFIT ASSIGNED RESIDENTIAL ADDRESS DATE OF BIRTH DD / MM / YYYY MEDICARE NUMBER PATIENT REF* No* EXPIRY DATE CHECKED X DATE OF SERVICE Medicare copy D L S I assign my right to benefits to the dental provider who has rendered the service s. Patient unable to sign - Dental provider who rendered the above service s SIGNATURE OF PATIENT / DATE Provider nu ...

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