Form

Patient Insurance Information

Patient Name

Date Of Birth

Insured's Name:

Date Of Birth

Social Security Number

Employer

Employer Address

Name of Dental Insurance Company

Insurance ID#

Insurance Address

Group #

Insurance Phone #

Photo of Insurance Card

Upload or drag files here

Name of Person Completing Form

For office use only

Lifetime Maximum:_________________ Paid out at: ___________ Deductible:________________

Accepts assignment of benefits: Yes ___ No___ Benefits used to date:________ Age Limit:_______

Effective Date: ________ Coordination of Benefits: Yes ___ No ___ Cont of TX Form? Yes___ No ___

Waiting Period: ____________ How benefits paid out?________________ Payor ID#_____________

Address for Claims:__________________________________________________________________

Spoke with whom:______________ Date Confirmed:_______ Staff: __________