Insurance and Financial Information Form

Your Name (required)

Your Email (required)

INSURANCE COVERAGE YesNo
INSURANCE COMPANY NAME
INSURANCE ADDRESS
INSURANCE PHONE:
SUBSCRIBER’S NAME
PATIENT’S RELATIONSHIP TO SUBSCRIBER SELFSPOUSEDEPENDENT
SUBSCRIBER’S BIRTHDAY
SUBSCRIBER’S SSN / ID #
GROUP / PROGRAM NUMBER
EMPLOYER (IF DIFFERENT FROM ABOVE)
EMPLOYER’S ADDRESS

SECONDARY COVERAGE YesNo
INSURANCE COMPANY NAME
INSURANCE ADDRESS
INSURANCE PHONE
SUBSCRIBER’S NAME:
PATIENT’S RELATIONSHIP TO SUBSCRIBER SELFSPOUSEDEPENDENT
SUBSCRIBER’S BIRTHDAY
SUBSCRIBER’S SSN / ID #
GROUP / PROGRAM NUMBER
EMPLOYER (IF DIFFERENT FROM ABOVE)
EMPLOYER’S ADDRESS

RELEASE INFORMATION
YOU MAY DISCUSS MY HEALTHCARE WITH

Health Care Providers YesNo
Insurance Companies YesNo
OTHERS (PLEASE PRINT)

CONFIRMATIONS
DO YOU PREFER A CONFIRMATION CALL No, it is unnecessaryYes, it is a helpful reminder

ASSIGNMENT & RELEASE

I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.
I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers or demonstrations.
I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

SIGNATURE - PATIENT / GUARDIAN _______________________DATE_________________
WITNESS SIGNATURE __________________________________DATE_________________