CDAnet Patient Information

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ALL PERSONAL INFORMATION WILL REMAIN COMPLETELY CONFIDENTIAL

Date (MM/DD/YYYY) *

I understand that the fees listed in this claim may not be covered by, or may exceed my plan benefits. I understand that I am financially responsible to CREDIT VALLEY ORAL SURGERY for the entire treatment amount. I certify that the information provided in this document is correct and complete to the best of my knowledge.

AUTHORIZED CONSENT TO RELEASE INFORMATION:

I authorize releaseto my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. This authorization shall continue until revoked.

Signature of SUBSCRIBER/Responsible Individual:

SUBSCRIBER Information:

Name of Policy Holder (Subscriber): *

Gender: *

Male
Female

Subscriber’s Date of Birth: *

Subscriber’s Address (if different from Patient’s):

Dental Insurance Company:

Group # (or Policy #, or Plan #):

Subscriber ID# or Certificate #:

Relationship of Patient to Subscriber: *

Self
Spouse
Common-Law Spouse
Child

If patient is a dependent and is a full time student, please indicate the name of the patient’s school:

If patient is a dependent and is challenged, please indicate:

Note: Are you claiming from more than one insurance company? *

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