NP HH Forms

Dental Insurance
Name of Insured

First NameLast Name
Employer
Employer Phone
Please enter a valid phone number.
Insurance Company
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone
Please enter a valid phone number.
Relationship to Patient
Birth date

MonthDayYear
Date
Social Security Number
Subscriber ID Number
Group Number
Please fill out if you know your policy benefits:
% Of: Preventative % Basic % Major %
Fiscal Year Date

MonthDayYear
Date
Annual Deductible . Annual Maximum and Amount Remaining .
Limits

CleaningsFluorideX-rays
ASSIGNMENT & RELEASE:I, the undersigned, certify that I (or my dependent) haveinsurance coverage with the above insurance company and assigndirectly to Silverstone Family Dental all insurance benefits. Iunderstand that I am financially responsible for all chargeswhether or not paid by insurance. I hereby authorize SilverstoneFamily Dental To release all information necessary to secure thepayment of benefits. I authorize the use of this signature for allinsurance submissions.

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Date

MonthDayYear
Date

Office Policy

I understand the responsibility for payment for dental services provided in this office for my dependents or me is mine, due and payable atthe time services are rendered. I further understand that a 1 ½ % finance charge per month (18% annually) will be added to any balanceover 60 days. In the event of default, I/we promise to pay legal interest on the indebtedness, together with collections costs and attorneyfees as consent to a credit check based on that information. I agree to be, and hereby am fully responsible for total payment and of thecharges for procedures performed in this office, including any amounts not covered by any dental insurance or prepayment plan that I/myspouse may have. Cancellation without a 48- hour notice or Failure to show for a scheduled appointment will result in a $100.00 perscheduled hour charge.
Signature

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Date

MonthDayYear
Date

Patient Information