Insurance and Billing Information

DENTAL INSURANCE AND BILLING

Dental Insurance Co.

Group #

Employer (or former if retired)

Is your plan a SELF PURCHASE or MEDICARE PLAN? (please choose one if applies)

Policyholder/Subscriber Name

Date of Birth

SSN #

ID #

YOU MUST PROVIDE EITHER THE SS# OR ID# IN ORDER TO LOCATE DENTAL BENEFITS

BILLING INFORMATION (if different than Patient info)

Name of person responsible for account

Relationship to patient

Phone

Address

Apartment Number

City

State

ZIP

Name of Employer

Work Phone

PATIENT INFORMATION

*From previous form. Please review and make any necessary changes and then Submit and Continue.

First Name

Last Name

Date of Birth

Gender

Address

Apartment Number

City

State

Zip

Home Phone

Cell Phone

Email Address

You prefer to receive calls at:

Status

Pharmacy Name

Pharmacy Phone Number

Emergency Contact Name

Emergency Contact Number

Relationship

Patient Employer

Occupation

Full Time Student?

School

Referred by

DENTAL INSURANCE AND BILLING

** YOU MUST PROVIDE EITHER THE SS# OR ID# IN ORDER TO LOCATE DENTAL BENEFITS **

BILLING INFORMATION (if different than Patient info)

PATIENT INFORMATION

YOU MUST PROVIDE EITHER THE SS# OR ID# IN ORDER TO LOCATE DENTAL BENEFITS