Insurance Information

Insurance Information
Is this replacing the current policy we have on file, or are we adding an additional policy?
Patient Full Name

First NameLast Name
Policy Holder Name (if different than patient)

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Provider Name
Plan/Policy Number (enter none if no policy number)
Member ID/Certificate Number
I acknowledge that all the information provided is used to process claims electronically. Apple Tree Dentistry accepts all insurance plans. If your policy permits, payment will be billed directly to your insurance company. For patients with a copay, the estimated out-of-pocket cost will be provided before your appointment begins, and collected day of treatment.
Signature
Should be Empty: