Dental Patient Information Form

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MIDWESTERN DENTAL
PATIENT INFORMATION
( ) Male
( ) Female
PATIENT NAME:
DATE OF BIRTH:
ADDRESS:
CITY:
STATE:
ZIP:
HOME PHONE:
WORK PHONE:
S.S.#:
PERSON TO CONTACT IN CASE OF EMERGENCY:
PHONE:
HOW DID YOU HEAR ABOUT US?
DRIVER LICENSE #:
INSURANCE INFORMATION
If you would like us to submit your claims for services directly to your Dental Insurance Company (Including Midwestern Dental Plans). You must provide
information about all dental benefit programs that could cover the patient. If you would prefer to pay for the services yourself and be reimbursed by your
Insurance you need not complete this section.
Please print the following information for the person who has the dental insurance:
Additional Dental Insurance
(If covered by)
What dental insurance do you have? __________________________________________________________
Dental insurance group #: __________________________________________________________________
Dental insurance phone #: __________________________________________________________________
Where do you work? ______________________________________________________________________
(
)
(
)
Work phone number: ______________________________________________________________________
Employee name who has dental insurance: ____________________________________________________
Date of birth of insurance holder: ____________________________________________________________
Social security number of insurance holder: ____________________________________________________
Union / Local Number:______________________________________________________________________
Are you hourly or salary?
__________________________________________________________________
Are you working or retired? __________________________________________________________________
Who is responsible for this account: __________________________________________________________
SIGNATURE AUTHORIZATION: I hereby authorize Midwestern Dental to execute in my name all payment application forms for treatment. The
determination of Midwestern Dental as treatment rendered shall be conclusive. I also authorize Midwestern Dental to sign my name to their computer
insurance forms when processing my account for payments.
SIGNATURE OF DENTAL INSURANCE HOLDER
DATE
FOR OFFICE USE ONLY
Patient Eligibility:
Benefit 1
( ) YES ( ) NO Date____________
Benefit 2
( ) YES ( ) NO Date____________
Person At Insurance Company
M / W Employee Initials
Picture I.D. Verified
To reorder call Accuform, (313) 271-5600

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