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16Harmony Family Dental
Harmony Family Dental
10103 N. DIVISION SUITE 201
SPOKANE, WA 99218
509-467-1562
Insurance Information
Primary Insurance
Insurance Holder's Name:
Date of Birth (mm/dd/yyyy):
Relationship to Patient:
Employer:
/
/
01
01
2027
Member ID:
Group ID:
Insurance Company Name:
Insurance Company Phone:
02
02
2026
-
-
03
03
2025
Insured's SSN:
Insurance Company's Address:
City:
State: ZIP Code:
04
04
2024
05
05
2023
AL
06
06
2022
Secondary Insurance
AR
07
07
2021
Insurance Holder's Name:
Date of Birth (mm/dd/yyyy):
Relationship to Patient:
Employer:
AZ
08
08
2020
/
/
CA
09
09
2019
01
01
2027
Member ID:
Group ID:
Insurance Company Name:
Insurance Company Phone:
CO
10
10
2018
02
02
2026
-
-
CT
11
11
2017
03
03
2025
DC
12
12
2016
Insured's SSN:
Insurance Company's Address:
City:
State: ZIP Code:
04
04
2024
DE
13
2015
05
05
2023
FL
14
2014
AL
06
06
2022
Authorization
GA
15
2013
AR
07
07
2021
All of the above information is correct to the best of my knowledge. I authorize use of this form on all my
HI
16
2012
AZ
08
08
2020
insurance submissions and I authorize the release of information to all my insurance companies. I
IA
17
2011
CA
09
09
2019
understand that I am responsible for my bill. I authorize Harmony Family Dental to act as my agent in
ID
18
2010
CO
10
10
2018
helping me to obtain payment from my insurance companies. I authorize payment to Harmony Family
IL
19
2009
CT
11
11
2017
Dental. I permit a copy of this authorization to be used in place of the original. I give Harmony Family
IN
20
2008
DC
12
12
2016
Dental, its employees, and/or other agents express prior consent to contact me at any/all phone numbers,
KS
21
2007
DE
13
2015
including cell numbers (by phone call or text message) and email addresses, for the purpose of treatment,
KY
22
2006
FL
14
2014
insurance, or payment.
LA
23
2005
GA
15
2013
Signature (Type your name to sign electronically, or print and sign):
Date (mm/dd/yyyy):
MA
24
2004
HI
16
2012
/
/
MD
25
2003
IA
17
2011
01
01
2017
ME
Consent for Treatment
26
2002
ID
18
2010
02
02
2018
MI
Patient Name:
27
2001
IL
19
2009
03
03
2019
MN
28
2000
IN
20
2008
04
04
2020
MO
29
1999
KS
21
2007
I hereby authorize the doctor or designated staff to take X-rays, study models, photographs, and other
05
05
2021
MS
30
1998
KY
22
2006
diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs of the
06
06
2022
MT
31
1997
LA
23
2005
above-named patient.
07
07
2023
NC
1996
MA
24
2004
Upon such diagnosis, I authorize the doctor or designated staff to perform all recommended treatment
08
08
2024
ND
1995
MD
25
2003
mutually agreed upon by us and to employ such assistance as required to provide proper care.
09
09
2025
NE
1994
ME
26
2002
I agree to the use of anesthetics, sedatives, and other medications as necessary. I fully understand
10
10
2026
NH
1993
MI
27
2001
that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of
11
11
2027
NJ
1992
MN
28
2000
any possible complications.
12
12
NM
1991
MO
29
1999
I have read, understood, and agree to the above treatment policy.
13
NV
1990
MS
30
1998
Signature (Type your name to sign electronically, or print and sign):
Date (mm/dd/yyyy):
14
NY
1989
MT
31
1997
/
/
15
OH
1988
NC
1996
01
01
2017
16
OK
1987
ND
1995
02
02
2018
17
OR
1986
NE
1994
03
03
2019
18
PA
1985
NH
Page 3/16
1993
04
04
2020
19
RI
1984
NJ
1992
05
05
2021
20
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