Step 1 of 250%This form is securely transmitted via an encrypted connection to PatientPrism.com which is an SSL secured and HIPAA compliant form solution.Dental Insurance Verification/UpdateParent's Email* Have there been any changes to your dental insurance coverage since your child’s last visit to our office? Please select one of the options below: There has been no change in the insurance plan information for* First Last Please be advised that if you do not inform us of changes to your dental insurance, we cannot guarantee that covered services will be paid in a timely manner. As a result, you may be responsible for paying all outstanding balances and seeking a reimbursement from your insurance company.Please type you name then check your email for signature verification*Date* Date Format: MM slash DD slash YYYY There have been changes in the insurance information for* First Last Insurance Company Name:Insurance Company PhoneInsurance Company Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Network Name:Group #Plan Name:Subscriber # or Member ID:Insured's Name* First Last Relationship to Patient:Insured's Birthday* Date Format: MM slash DD slash YYYY Insured's Social Security #:*Insured's Employer:Does the member have Secondary Insurance*YesNo* We do not routinely file to a secondary insurance company, however we are often required to inform the primary insurance of any secondary plan that may cover services for the patient.PLEASE REMEMBER TO BRING YOUR INSURANCE CARD ALONG TO THE VISIT SO WE MAY MAKE A COPY FOR OUR RECORDS. THANK YOU!Please type you name then check your email for signature verification*Date* Date Format: MM slash DD slash YYYY * Date Format: MM slash DD slash YYYY DateMEDICAL HISTORY UPDATEPatient's Name* First Last Patient's Date of Birth* Date Format: MM slash DD slash YYYY *MaleFemaleIMPORTANT NOTICE: WE REQUIRE A PARENT OR LEGAL GUARDIAN BE PRESENT AT ALL APPOINTMENTS. PLEASE NOTIFY THE FRONT DESK IF YOU ARE NOT THE PARENT OR LEGAL GUARDIAN OF THE PATIENT.Has your child’s medical history changed since your last visit to this office?YesNoIf yes, please explain:Is your child currently taking any medication?YesNoIf yes, please explain: Has your child been in the hospital in the last year?YesNoIf yes, please explain:Is there anything you feel we should know about your child’s health history?YesNoIf yes, please explain:Does your child have any food or fruit allergies?YesNoIf yes, please explain: What do you or your child like most about coming to our office?Is there anything we could do to make your visits to our office better?I understand the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and that it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff of Pediatric Dentistry of Brandon PA to perform the necessary dental services my child may need. I understand that I am responsible for the cost of these dental services at the time of the visit, unless prior arrangements have been made.Please type you name then check your email for signature verification*Date* Date Format: MM slash DD slash YYYY
