Insurance

Insurance
This form must be signed by the plan member of the insurance policy
Please understand that we are not directly linked with any insurance companies.

We deal with hundreds of different insurance plans and it is impossible for us to know the details of each one.

It is up to you to know the limitations of your plan and to pay any difference between what insurance pays and the cost of treatment.

Any insurance balances outstanding after 90 days will become your responsibility and insurance forms will be provided so you can get reimbursed directly from your insurance company.

Should an exorbitant amount of time be required to deal with your insurance, you will be given the option for us to handle however an administration fee will apply.

By signing below I consent to the above terms.
Insurance Company*
Other Insurance Company
Policy/Group #
Certificate/ID #*
Plan Member Name*

First NameLast Name
Plan Member Date of Birth (MM.DD.YYYY)*

MonthDayYear
Date
People covered under this plan
I hereby assign my benefits, payable from claims submitted electronically, to Golden Dental Centre and authorize payment directly to them. This authorization shall continue in effect until the undersigned revokes the same.
Date*

MonthDayYear
Date
Signature*
Should be Empty: