Insurance Form

*PLEASE PROVIDE OUR FRONT OFFICE STAFF WITH YOUR DENTAL INSURANCE CARD*

Please complete this sheet as accurately as possible. Providing us with all of the requested information will help to expedite your claims processing and payment by your dental insurance company.

Name of the individual that carries the insurance
Their date of birth
Their SS#
Their Employer
Name of Dental Insurance Company
ID#
Group #
Dental Insurance Company Phone #
Address to mail Dental Claims
Date
Name
I understand that the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. I will notify the doctor of any change in my health or medication

Dr. Philip R. Jackson Family Dentistry - Dentist Columbia SC

DR. PHILIP R. JACKSON

Insurance Form