Current Patient Form

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/Update
Parent'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 has been changes in the insurance information for
*
First Last
Insurance Company Name:
Insurance Company Phone
Insurance Company Address
Street Address City 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*
- Yes
- No
* 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

Step 1 of 2

Dental Insurance Verification/Update

MEDICAL HISTORY UPDATE