Patient Information Form (Page 2 of 2) in pdf

Dental Insurance Information

Name of Insured: ___________________________________________________________________________________________________

Relationship to Patient: ____________________________________________________________________________________________

Insured’s Date of Birth: ____________________________________________ Insured’s SSN: _____________________________

Employer:_________________________________________________________________________ Date Employed:_______________

Address of Employer: ___________________________________ City:_________________________ State____ Zip Code:________

Employer Phone: ____________________________

Dental Insurance Company: __________________________________________________________________

Group #: ___________________________

Policy/ID #:________________________

Ins. Co. Address: _______________________________________________________ City: ____________________________ State ____

Insurance Co. Telephone #: __________________________________________

Zip Code: ___________________________

Assignment and Release

As a courtesy to you, we can accept assignment of benefit payments from most insurance companies.

Patients who carry dental insurance understand that all services are charged directly to the patient, and that he or she

is personally responsible for payment of all dental services not paid by the insurance company.

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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 or Guardian)

Date: _______________________________________________________________________

Patient Information Form Page 2