Insurance Form

Patient Information
Patient Name*
Date of Birth*
Primary Insurance Information
Insured Full Name*
DOB*
Insurance Company*
Member ID/SSN*
Group#*
Employer*
Insurance Phone Number*
Secondary Insurance Information
Insured Full Name
DOB
Insurance Company
Member ID/SSN
Group#
Employer
Insurance Phone Number
Authorization to assign benefits and release medical information
For services rendered, I hereby assign payment from my insurance company to Elite Pediatric Dentistry. I shall be financially responsible to pay for non-covered charges, unpaid balances, deductibles or coinsurance.
Responsible Party Signature*
Your Name
Your Name
Your Name
Date*

Patient Information