Wazio Orthodontics
Orthodontic Insurance Information
Patient Name:
Date of Birth:
Patient School (if student):
City:
Primary Policy Holder Information
Name:
ID# or SS:
Date of Birth:
Relationship to Patient:
Martial Status
Employer
Dental Insurance Company
Group #
Insurance. Effective Date
Insurance Co. Address
City
State
Zip
Insurace Company Telephone No.
I authorize release of information relating to this claim. Electronic Signature
Date:
I hearby authorize payment directly to Wazio Orthodontics the group insurance benefits otherwise payable to me. Electronic Signature
Date: