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Dental Insurance - For New Patients or Changes
Policy Holder's First Name
Policy Holder's Last Name
Date Of Birth
List patient(s) name/birthdate covered under policy
Will this be the Primary or Secondary Dental Plan?
Employer/Group Name
Insurance Company Name
Insurance Company Address
Member ID#
Insurance Phone Number
Group #
SSN
Financial Disclosure: Our office submits claims and pre-estimates to insurance on your behalf as a courtesy; however, your insurance is a contract between you and the carrier. Final coverage is determined by the insurance once claims are processed. We can only provide an estimate based on your current coverage and require patient portion to be paid at the time of service. For major procedures, you have the option to discuss a payment arrangement prior to the rendering of any services. If your policy changes, your benefits may be different. Please notify us of any changes immediately. RECOMMENDED TREATMENT IS NOT BASED ON COVERAGE. You are financially responsible for all professional charges not covered by insurance. I understand and fully agree with all mentioned above.
Assignment of Benefits: I authorize for insurance payments to be made directly to the dentist(s) involved in the patients' care
Patient/Legal Guardian Signature
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