New Insurance Form

Primary Insurance Company*

Plan Holder Name*

First NameLast Name

Plan Holder Date of Birth*

Date

Group/Policy #*

Certificate/ID#*

Secondary Insurance Company

(If Any)

Secondary Plan Holder Name

First NameLast Name

Date of Birth

Date

Group/Policy#

Certificate/ID#

ASSIGNMENT OF BENEFITS AND PAYMENT POLICY

This office is willing to accept direct payment from your dental plan, should your plan allow for assignment of benefits. Dental plans in the marketplace today are too numerous and varied to allow us to know the details of all of them. Your particular dental plan may or may not cover the full extent of the costs you incur for your dental treatment. This can occur because the fees in our office are based on factors which may not have been considered by your insurance carrier. Furthermore, there may be certain procedures performed which are not covered by your dental plan. These factors are beyond our control. We advice you to review your dental plan carefully to ensure you understand the exclusions and limitations of your plan. If your dental plan does not cover the full cost of treatment, you will be responsible for any difference between the amount paid by your plan and the amount charges for your treatment.

Payment for dental services is expected when treatment is rendered. You will be informed of your payment or co-pay responsibility at the time treatment is completed so that you may make payment at that visit. I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for any claim. I authorize that the doctor can use my records if he/she so determines. I certify that I have read the contents of this form, filled in completely and accurately to the best of my knowledge and do realize the risks and limitations involved.

Patient/Guardian Signature*

Date

EverBrite

DENTAL