Dental Insurance Authorization Form

Dental Insurance Authorization Form

HIPPA Compliant Form
Do you have Dental Insurance?

Yes No Not Sure
Patient's Name *

First Name Last Name
Primary Policy Holder's Name *

First Name Last Name
Primary Policy Holder's D.O.B. *

Month Day Year
Date
Relationship to Patient *

Self Parent Spouse
Patient's Status *

Full Time Student Part Time Student Neither
Insurance Carrier *
Member I.D. # or Social Security # *
Group #
Insurance Company Phone # *

Area Code Phone Number
Insurance Company Address

Street Address

City State / Province

Postal / Zip Code
Is There Another Dental Insurance? *

Yes No
Secondary Policy Holder's Name

First Name Last Name
Secondary Policy Holder's D.O.B.

Month Day Year
Date
Relationship to Patient

Self Parent Spouse
Insurance Carrier
Member I.D. # or Social Security #
Group #
Insurance Company Phone #

Area Code Phone Number
Insurance Company Address

Street Address

City State / Province

Postal / Zip Code
I authorize release of information to all my Insurnace Companies and allow my doctors office to ask as my agent to obtain payments. In addition, I permit this authorization of Signiture on File to be used in place of my original signiture.

I understand that if the insurance does pay the full estimated coverage, I will be responsible for the any remaining balance.
Date of Signature *

Month Day Year
Date
Insured's or Authorized Person's Signature *

Clear
Should be Empty: