Dental Insurance
Dr. Daniel C. Sluyk, DDS
Primary Dental Insurance
Insurance Plan Name:
Phone Number for Provider Services:
Name of Insured:
First Name
Middle Name
Last Name
Insured’s Birth Date
Plan ID #
Insured’s SSN:
Group #
Insured’s Address:
Street Address
Street Address Line 2
City
State
Country
Postal
Address 2
Street Address
Street Address Line 2
City
State
Country
Postal
Patient’s Relationship to insured:
Self
Spouse
Child
Other
This field is required.
Secondary Dental Insurance
Insurance Plan Name:
Phone Number for Provider Services:
Name of Insured:
First Name
Middle Name
Last Name
Insured’s Birth Date
Plan ID #
Insured’s SSN:
Group #
Insured’s Address:
Street Address
Street Address Line 2
City
State
Country
Postal
Address 2
Street Address
Street Address Line 2
City
State
Country
Postal
Patient’s Relationship to insured:
Self
Spouse
Child
Other
This field is required.
Insurance Authorization - please complete for payment of insurance benefit
• I authorize my insurance(s) to pay my benefits directly to the dentist for all services rendered.
• I authorize the use of this electronic signature on all insurance submissions.
• I authorize the dentist to release all information necessary to secure the payment of benefits.
• I understand that I am financially responsible for all charges, whether or not paid by insurance.
This field is required.
Name
First Name
Last Name
Signature
Clear
Signature is mandatory.
Submit