Insurance Information/Update | Christopherson Orthodontics

orthogr.com - Child Registration Form

Patient Information

Patient Name *

Dental Insurance Information

Primary Dental Insurance
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation
Policy Holder's Social Security Number
Policy Holder's Birth Date
Employer
Work Phone Number

Secondary Dental Insurance

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation

Policy Holder's Social Security Number

Policy Holder's Date of Birth

Employer

Work Phone Number

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

Patient Signature and/or Responsible Party *

Date *