Insurance Information and Agreement Form

Hidden
Date
YYYY dash MM dash DD
Insurance Information
Insurance Policy Holder:*
First Last
Policy Holder Date Of Birth:*
YYYY dash MM dash DD
Insurance Company:*
Insurance Company Name:*
Insurance Company Phone # :*
Certificate # :*
Group # :*
List of others insured under this policy:
First Name Last Name Date Of Birth Relationship to Policy Holder
Direct Billing to Insurance Agreement
The clinic will accept to receive payments directly from my insurance company with the following provisions:
- I, the account holder will be responsible to pay any amount not covered by the insurance company at the time the services are provided to anyone covered under this policy.
- If my insurance company fails to settle any submitted claim within 20 days from the date of claim submission, I will be responsible to pay the full amount and have my insurance reimburse me instead. Any unpaid balance over 30 days from the day of treatment will be subject to interest accumulation of two (2%) percent per month.
Policy Agreement*
- I have read, understood and agreed to the above conditions.
Account Holder:*
First Last
Mobile Phone # :
Other Phone # :
_________________________________
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Insurance Information

First Name	Last Name	Date Of Birth	Relationship to Policy Holder