Adult Patient Information l Moriarty Dental Group, PLC l Webster City IA

Spouse/Partner's Name

Emergency Contact Name

Phone Number

Relation to you

Address

City

State

Zip

Primary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation

Policy Holder's SSN

Policy Holder's Date of Birth

Employer

Work Phone Number

Co-pay (if known)

Deductible (if known)

Secondary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation

Policy Holder's SSN

Policy Holder's Date of Birth

Employer

Work Phone Number

Co-pay (if known)

Deductible (if known)

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.

I understand that where appropriate, credit bureau reports may be obtained.

Patient Signature and/or Responsible Party

Date

Adult Patient Information

Patient Information

Spouse/Emergency Contact Information

Insurance Information

Dental History

Medical History

Authorization