We will file your insurance as a courtesy. However, it is important for you to understand that you
are solely responsible for your account. Therefore, it is important that all insurance information is
disclosed at this time. Please make sure that your information is accurate and up to date.
Primary Dental Insurance
Policy Holder Name: ______________________________________________________
Date of Birth: __________________________ SS#: _____________________________
Employer: _______________________________________________________________
Insurance Carrier Name: ___________________________________________________
Customer Service Phone Number: ____________________________________________
Claims Address: __________________________________________________________
Id#: ___________________________________ Group: __________________________
Secondary Dental Insurance
Policy Holder Name: ______________________________________________________
Date of Birth: __________________________ SS#: _____________________________
Employer: _______________________________________________________________
Insurance Carrier Name: ___________________________________________________
Customer Service Phone Number: ____________________________________________
Claims Address: __________________________________________________________
Id#: ___________________________________ Group: __________________________
Primary Medical Insurance
Policy Holder Name: ______________________________________________________
Date of Birth: __________________________ SS#: _____________________________
Employer: _______________________________________________________________
Insurance Carrier Name: ___________________________________________________
Customer Service Phone Number: ____________________________________________
Claims Address: __________________________________________________________
Id#: ___________________________________ Group: __________________________
Secondary Medical Insurance
Policy Holder Name: ______________________________________________________
Date of Birth: __________________________ SS#: _____________________________
Employer: _______________________________________________________________
Insurance Carrier Name: ___________________________________________________
Customer Service Phone Number: ____________________________________________
Claims Address: __________________________________________________________
Id#: ___________________________________ Group: __________________________
1157 First Colonial Rd., Suite 101, Virginia Beach, VA, 23454 • 757-­‐496-­‐8066