Smiles Encino - Dental Insurance

Dental Insurance
First
Last
Insurance Plan Name
Main Subscriber
Main Subscriber Name

First NameLast Name
Birthday
Gender
SSN
Subscriber ID
Group
Address
SuiteApt
City
State
Zip
Insurance Plan Name
Main Subscriber
Subscriber Name

First NameLast Name
Birthday
Subscriber ID
Group
Authorization to pay benefits to dentist I here by authorize assignment of benefits (insurance payments) be paid directly to California Smile Maker and or other dental benefits, if any, otherwise payable to me for services but not to exceed the benefits provided for covered services.
PatientGuardian Signature
Date

MonthDayYear
Name if not the patient
Relationship to the patient
Should be Empty: