Insurance Information Update

Required fields

If you have orthodontic coverage, the following information is required for submitting an insurance claim. Please complete the entire section to ensure proper billing. Thank you.

Insured's Name

Insured's Date of Birth

Group Number

Policy ID/Social Security #

Insurance Company

Insurance Company Address

Phone Number

Does this policy have orthodontic benefits?

Yes

Don't Know

Financial Responsibility

Who is financially responsible for this account?

Address

City

State

Zip Code

Cell Phone

Home Phone

Who will be responsible for bringing the patient to their orthodontic appointments?

Relationship to patient

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Signature of Patient (Parent or Guardian if minor)

Date

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