Insurance Form Insurance Form Patient InformationPatient Name*Date of Birth* Date Format: MM slash DD slash YYYY Primary Insurance InformationInsured Full Name*DOB* Date Format: MM slash DD slash YYYY Insurance Company*Member ID/SSN*Group#*Employer*Insurance Phone Number* Secondary Insurance InformationInsured Full NameDOB Date Format: MM slash DD slash YYYY Insurance CompanyMember ID/SSNGroup#EmployerInsurance 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