Insurance Information Update Form

**This an encrypted form, so that your information is secure. This complies with HITECH standards and is HIPAA compliant**

Please have your Dental Insurance Card ready when you submit this information. We need this information at least 2 business days before your appointment, if you would like to utilize your benefits. Verification of Insurance benefits takes time and is completed when we are not with patients. Thank you for providing this information as early as possible.

New Patients: *please complete the New Patient Forms – this form is for existing patients* . This information is for the patient:

Steckelberg Insurance Update Form

Patient Information

* Patient First and Last Name: (Required)

Birth Date:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type office home mobile

Secondary Phone Number:

Phone Type office home mobile

Is It Okay to Text You Appointment Reminders? Yes No

E-mail:

Dental Insurance Information

Denal Insurance Company Name:

Dental Insurance Address (see card):

Dental Insurance Phone Number for Providers:

Policy Holder / Subscriber's First and Last Name:

Policy Holder / Subscriber's Birth Date:

Policy Holder / Subscriber's ID Number:

If no ID number listed, we will need the Policy Holder / Subscriber's Social Security Number:

Policy Holder / Subscriber's Employer:

Policy Holder / Subscriber's Employer's Address:

Comments:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

Submitted by:

Date:

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