Insurance Information Form

Insurance Information

Submit your health history form online to your orthodontist today. Save time at the orthodontist's office and fill out your insurance information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.
PLEASE NOTE: The requested information relates to the insurance subscriber, not the patient. Please review each question carefully before answering.
In order to assist in determining your orthodontic insurance benefit, the following information is necessary:
Patient Name*

First NameMiddle NameLast Name
Name of Insured
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #**
Social Security Number is required in order to verify insurance.
Telephone*
Please enter a valid phone number.
Employer**
Dental ID Number
Insurance Company:**
Policy/Group #:**
Address of Insurance Company:**
Insurance Company Telephone*
Please enter a valid phone number.
If there is dual coverage or another dental plan, please complete the following section:
Is patient covered under another dental plan?**

YesNo
Name of Insured*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #
Telephone
Please enter a valid phone number.
Employer
Insurance Company:
Policy/Group #:
Address of Insurance Company:
Insurance Company Telephone:
Signatures
Release*

I hereby authorize release of any information relating to this claim.
Insurance*

I hereby authorize payment of insurance benefits directly to Vinson Orthodontics.
Signature*

I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above.
Signature

Clear
Should be Empty:

Insurance Information

In order to assist in determining your orthodontic insurance benefit, the following information is necessary:

If there is dual coverage or another dental plan, please complete the following section:

Signatures