Insurance Form

General Patient Information

Primary Dental Insurance

Policy Holder
Relationship to Patient

Secondary Dental Insurance

Policy Holder
Relationship to Patient

General Medical Insurance

Policy Holder
Relationship to Patient

ASSIGNMENT OF BENEFITS & AUTHORIZATION TO RELEASE INFORMATION

If I am entitled to benefits under any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.

I give my consent for examination and treatment.

I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.

This information maybe released to

If patient is 18 years of age or younger, please provide Parent/Guardian Signature:

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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