Get the free Patient Insurance Information Sheet-1

Robert. Elliott, DMD, MS CaryPediatricDentistryJulieR. Molina, DDS, MS 540NewWaverlyPlaceSuite300Cary,NC27518Telephone:(919)8521322FAX:(919)8521230 PatientInsuranceInformation Ourofficeisconsideredoutofnetworkforallinsurancecompanies.

How to fill out patient insurance information sheet-1

How to fill out patient insurance information sheet-1:

1. Start by writing your full legal name in the designated space. Include your first name, middle name (if applicable), and last name.
2. Provide your date of birth in the format of month, day, and year. This is important for accurately identifying the patient.
3. Fill in your current address, including the street address, city, state, and zip code. Make sure to double-check the accuracy of this information.
4. Enter your primary phone number, which should be a reliable contact number where you can be reached.
5. Include your email address if you have one. This is optional, but it can be useful for communication purposes.
6. Indicate your gender by checking the appropriate box. This information helps healthcare providers tailor their services to your specific needs.
7. Provide your social security number. This is a crucial piece of information that assists with insurance and billing processes.
8. Fill in your insurance policy number accurately. This is essential for healthcare providers to verify coverage and process claims.
9. Specify the name and address of your insurance company. This allows the healthcare facility to contact your insurer for any necessary authorizations or billing inquiries.
10. If you have secondary insurance, provide the details of your secondary insurance policy, including the policy number and the name/address of the insurance company.
11. Sign and date the patient insurance information sheet-1 to confirm that the information provided is accurate and complete.

Who needs patient insurance information sheet-1?

1. Individuals who are visiting a healthcare facility as patients should be required to fill out the patient insurance information sheet-1.
2. Patients who have health insurance coverage or who are eligible for insurance benefits need to complete this form.
3. People who are seeking medical treatment or services that may require insurance authorization and billing should provide their insurance information on this sheet.

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