DENTAL INSURANCE UPDATE

Paul Y. Lin, D.D.S.

Cosmetic, Restorative, & General Dentistry
DENTAL INSURANCE UPDATE
This form is ONLY for existing patients.

If you are not an existing patient, please complete a new PATIENT REGISTRATION FORM.
Please check here if you are an existing patient.
Patient’s Name

FirstMiddle InitialLast
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Social Security Number
Format: 000 - 00 - 0000.
Are You Updating (Select One)
PRIMARY INSURANCE:
You Are Covered Under This Insurance Through (Select One)
Name of Employer Providing Insurance
Name of Dental Insurance
Address to Submit Claims to
Phone Number to Check Eligibility (usually 1-800 #)Format: (000) 000-0000.
Insurance Member (Subscriber) ID
If one is provided other than SSN
If you are covered through SOMEONE OTHER THAN YOURSELF, please complete this section for the primary insured (primary subscriber).
Name of The Primary Insured (Subscriber, Whom You Are Covered Under)

FirstMiddle Initial Last
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Birth
Social Security NumberFormat: 000 - 00 - 0000.
Insurance Member (Subscriber) ID
If one is provided other than SSN
SECONDARY INSURANCE:
Your Secondary Insurance Is Covered Under (Select One)
If you are covered through SOMEONE OTHER THAN YOURSELF, please complete this section for the primary insured (primary subscriber).
Name of The Subscriber (Whom You Are Covered Under)

FirstMiddle Initial Last
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Birth
Social Security Number of The Subscriber
Format: 000 - 00 - 0000.
Name of Employer Providing Insurance
Name of Dental Insurance
Address to Submit Claims to
Phone Number to Check Eligibility (usually 1-800 #)Format: (000) 000-0000.
Insurance Member(Subscriber) ID
If one is provided other than SSN
Please contact the office for any questions or issues.

82 Townsend Street,

San Francisco, CA 94107

415. 543.6882

info@PaulYLinDDS.com

www.PaulYLinDDS.com
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