Insurance Information Update
If you have orthodontic coverage, the following information is required for submitting an insurance claim. Please complete the entire section to ensure proper billing. Thank you.
Insured's Date of Birth
Policy ID/Social Security #
Insurance Company Address
Does this policy have orthodontic benefits?
Who is financially responsible for this account?
Select your option
District Of Columbia
Who will be responsible for bringing the patient to their orthodontic appointments?
Relationship to patient
Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.
Signature of Patient (Parent or Guardian if minor)
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