Dental Insurance Information | Blue Ridge Dental Center

Dental Insurance Information
Employee/Subscriber (the name of the person who signed up for the coverage)
Name
First Last
Date
MM slash DD slash YYYY
SS# or ID#
Name of Employer
Insurance Company
Group Number
Insurance Company Mailing Address
Street Address Address Line 2 City State ZIP Code
Insurance Company Phone
Effective Date
MM slash DD slash YYYY
Spouse
Birthdate
MM slash DD slash YYYY
Child 1
Birthdate
MM slash DD slash YYYY
Full-time College Student?
Name of School
Child 2
Birthdate
MM slash DD slash YYYY
Full-time College Student?
Name of School
Child 3
Birthdate
MM slash DD slash YYYY
Full-time College Student?
Name of School
ARE YOU COVERED UNDER ANOTHER DENTAL INSURANCE CO.?
Employee/Subscriber
First Last
Birthdate
MM slash DD slash YYYY
Social Security #
Name of Employer
Insurance Co.
Group #
Insurance Co. Mailing Address
Street Address Address Line 2 City State ZIP Code
Insurance Co. Phone
Effective Date
MM slash DD slash YYYY
Family Members Covered (list all)
Signature
The undersigned, hereby authorizes the release of my information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes Blue Ridge Dental Center, for services rendered without obtaining my signature on each and every claim to be submitted for me and/or dependents. I will be bound by this signature as though the undersigned had personally signed the particular date.