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New Insurance Form

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New Insurance Form

New Insurance Form

Please provide your insurance details so our team can verify your coverage before your visit.

Patient Information

Patient full name *

Email address *

Phone number *

Primary Dental Insurance

Employer name *

Group number *

Employer telephone *

Insurance company name *

Insurance telephone *

Subscriber name *

Subscriber date of birth *

SSN / ID / Contract number *

Relationship to patient *

Secondary / Medical Insurance (Optional)

Employer name

Group number

Employer telephone

Insurance company name

Insurance telephone

Subscriber name

Subscriber date of birth

SSN / ID / Contract number

Relationship to patient

Insurance Authorization

I certify that I, and/or my dependent(s), have insurance coverage with the company or companies listed above and assign directly to Upper East Dental Innovations PLLC all insurance benefits, if any, otherwise payable to me for services rendered.

I authorize the use of my signature on all insurance submissions and authorize Upper East Dental Innovations PLLC to release information necessary to process insurance claims and determine benefits. I understand that I am financially responsible for all charges whether paid by insurance or not.

Signature of patient, guardian, or representative (type full name) *

Date *

Printed name of patient, guardian, or representative *

Identification Uploads (Optional)

If you no longer have a physical ID, you may leave these uploads empty.

PhotoTap to upload fileFront of IDTap to upload PDFBack of IDTap to upload PDF

New Insurance Form