Insurance Form

Patient Information
Patient Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
Primary Insurance Information
Insured Full Name*
DOB*
Date Format: MM slash DD slash YYYY
Insurance Company*
Member ID/SSN*
Group#*
Employer*
Insurance Phone Number*
Secondary Insurance Information
Insured Full Name
DOB
Date Format: MM slash DD slash YYYY
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*
Date*
Date Format: MM slash DD slash YYYY

Patient Information