Dental Insurance Coverage
Primary & Secondary

Patient Name:*
DOB:*
Home Address:*
E-mail:
Home Phone:
-
Cell Phone:
-
Texting Capable:
Work Phone:
-
Social Security No:
Employer:
Employment Date:

Primary Dental Insurance

Insurance Company:
Company Address:
Company Phone:*
-
Effective Date:
Group Number:
ID Number:

Secondary(2nd) Dental Insurance

2nd Insurance Co.:
2nd Co. Address:
2nd Co. Phone:*
-
2nd Effective Date:
2nd Group Number:
2nd ID Number:

Authorization to Release Information:

The information is correct to the best of my knowledge and the electronic submission of this form constitutes my electronic signature and authorization to proceed.  I hereby authorize any dentist, physician, hospital, pharmacy, insurance company or their approved agents to release any medical or dental information treatment or benefits payable for this claim to the Plan Administrator or its authorized agent for the purpose of validating and determining benefits payable in connection with this claim(s).  I understand I may receive a copy of this claim.  I further authorize payment of this claim directly to dental services provider otherwise payable to me. 

Human Verification:

facebookfan