Order Number DENTAL INSURANCE AND BILLING Dental Insurance Co. Group # Employer (or former if retired) Policyholder/Subscriber Name Date of Birth * SSN # ID # BILLING INFORMATION (if different than Patient info) Name of person responsible for account Relationship to patient Phone Address Apartment Number City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 Patient Employer Occupation Full Time Student? School Referred by
