Serenity Family Dental of Burlington

Insurance Form
GENERAL INFORMATION
Patient Name*
Date of Birth
PRIMARY DENTAL INSURANCE
Policy Holder

SelfOther
Policy Holder Name (if not patient)
Relationship to Patient

SelfSpouseParentLegal GuardianPartnerOther
If other, please specify
Name of Employer
Work Phone
Address

Street Address

Street Address Line 2

CityState

Zip Code
Policy Holder Date of Birth
Insurance Company
Insurance Group #
Insurance Plan #
Effective Date
SECONDARY DENTAL INSURANCE
Policy Holder

SelfOther
Policy Holder Name (if not patient)
Relationship to Patient

SelfSpouseParentLegal GuardianPartnerOther
If other, please specify
Name of Employer
Work Phone
Address

Street Address

Street Address Line 2

CityState

Zip Code
Policy Holder Date of Birth
Insurance Company
Insurance Group #
Insurance Plan #
Effective Date
If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer, and convey the benefits payable under such program, policy, or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf. I hereby accept responsibility for and agree to pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.
Initial
I give my consent for examination and treatment.
Initial
I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.
This information may be released to

SpouseFamilyFriendOther Treating Physician(s)Do Not Release my Medical Information
SIGNATURE
NOTE: Both the Doctor and the patient are encouraged to discuss any relevant patient health issues before treatment.
Name of Patient/Legal Guardian
Date
Signature of Patient/Legal Guardian

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Cancelof
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Should be Empty:

Insurance Form

GENERAL INFORMATION

PRIMARY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

SIGNATURE