EmailMeForm
Seaman Family Dentistry Insurance Info
New Insurance Form
Instructions: Please provide as much information as possible, so we are able to accurately enter and verify your insurance plan, as well as correctly file your dental claims.
PATIENT AND INSURED INFORMATION:
Your Name:
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First
Last
Your Date of Birth:
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List the name of EACH patient who is covered by this insurance plan.
Name of Insured (patient carrying the insurance):
*
Insured's Social Security Number OR Insurance ID #:
*
Insured's date of birth:
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DD
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YYYY
Your relationship to the insured:
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Self
Spouse
Child of Insured
Other Covered Dependent
Type of Insurance Plan Change
Same Employer New Dental Plan
New Employer Dental Plan
New Individual Plan (non-employer based)
Please choose the reason you have a new dental plan.
EMPLOYER and INSURANCE COMPANY INFORMATION:
Employer Name:
*
If this insurance is NOT through an employer, type "SELF-INSURED" in the above box.
Name of Insurance Company:
*
Insurance Company Address:
Insurance Company Phone:
*
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Special Information about this plan:
Please tell us if this policy REPLACES AN EXISTING ONE, is a SECONDARY policy, etc, anything that will help us understand the change you are making.
OTHER CHANGES:
Use the boxes below to provide us with any other information about the changes in this form OR for other changes which need to be made, but were not mentioned earlier.
Additional Information or Changes:
Phone number to contact you if we have questions:
*
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Your email address:
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I certify that information contained in this form is true and complete.
Initial
*
Today's Date:
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