Souhegan Valley Dental

Souhegan Valley Dental

Insurance Information Form
Name

First NameMiddle InitialLast Name
Email
example@example.com
Primary Dental Insurance Information

While entering insurance information, please note that DENTAL insurance and MEDICAL insurance are typically different. We are only able to submit claims to your insurance company if information is correct.While our office does bill to insurance, retrieve breakdowns of your benefits, and create treatment plans as a courtesy to our patients, insurance in ultimately the patient's responsibility. If you have any questions regarding insurance in general or your specific plan, please do not hesitate to ask. We are always happy to help!
Name of Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone Number
Please enter a valid phone number.
Policy Number / Subscriber ID
Group Number
Name of Insured (Policy Holder)

First NameLast Name
Policy Holder DOB

MonthDayYear
Date
Relationship to Insured (Policy Holder)

SelfSpouseChildOther
Is this plan purchased through an employer?

YesNo
Please provide the Name of the Employer
Do you have a Secondary Dental Insurance?

YesNo

Sign Form

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Date

MonthDayYear
Date
Relationship to Patient:
Name

First NameLast Name
Signature

Clear
Should be Empty:

Primary Dental Insurance Information