Get the free SUBSCRIBER - Peddicord Family Dentistry Ankeny, IA

SUBSCRIBER Authorization for Signature on File I hereby authorize and direct payment of the dental benefits otherwise payable to me directly to the office of Peddicord Family Dentistry. This Signature on File will be valid from this date and shall expire in one year. A photocopy of this document may act as an original. Today s Date Signature of Subscriber Expiration Date Witnessed By PATIENT Release of Information / Financial Responsibility affix my name to any and all claims or documents as...

How to fill out subscriber - peddicord family

How to fill out subscriber - peddicord family

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Subscriber - Peddicord family refers to a group of individuals who are covered under the same health insurance plan and share the same policyholder.

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The information that must be reported on subscriber - peddicord family includes the names, dates of birth, relationships to the subscriber, and social security numbers of all individuals covered under the health insurance plan.