Insurance Verification

Patient's Name(Required)

Insurance Company Name(Required)

Insured's Name(Required)

Relation to Patient(Required)

Group Number

Insured's Policy ID Number(Required)

Insured's Date of Birth

Insured's Company Phone

Insured's SSN

Insured's Employer

Secondary Insurance

Insured's Name

Relation to Patient

Group Number

Insured's Policy ID Number

Insured's Date of Birth

Insurance Company Phone

Insured's SSN

Insured's Employer

Insured's Billing Address

Our Financial Policy and How it Works For You

Whether you are paying with cash or using insurance, you are always ultimately responsible for your bill. We expect payment at the time of service, so please make arrangements to pay when you arrive for your appointments.

Our Responsibilities

We will verify your insurance benefits.
We will bill your insurance for you as a courtesy.
We will correct any errors we have made when there is a billing dispute.
We will provide guidance in getting your bills paid.

Your Responsibilities

Please know and understand your insurance coverage.
Please pay your deductible, coinsurance or copayment at the time of your treatment.
Please read and keep your Explanation of Benefits statements from your insurance.
Please follow up promptly with claims that are not paid by your insurance company, or you will be billed directly for them.

Authorization to Release Information(Required)

I authorize the release of the above provided information and any medical information necessary to: 1) provide for adequate professional coverage in the absence of the primary doctor; 2) to verify insurance coverage; and 3) to file a claim for insurance benefits related to professional services rendered.

Patient Name(Required)

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Insurance Company(Required)

Authorization to Assignment of Benefits(Required)

I authorize direct payment of insurance benefits from (Insurance Company) to Pediatric Dentistry for professional services rendered.

Parent / Responsible Party(Required)

Email Address