To help us better serve you, please complete the following forms to the best of your ability. If you have questions, do not hesitate to let us know. Thank you for choosing our office!

COORDINATION OF BENEFITS

Thank you for providing us with another insurance policy. Before we can verify and or/submit claims, we ask that you please reach out to both of your insurance companies and inform them of the other policy for your child/ children. The insurance companies will determine which policy is primary and which is secondary. At this point, they will inform you of the filing order.

Why are we asking you to do this?

1. THE POLICY HOLDER DOES NOT DECIDE THE FILING ORDER IN WHICH THE INSURANCE COMPANIES PAY BENEFITS, THE INSURANCE COMPANIES DECIDE.

2. Your insurance companies will ask for your personal relationship information that we do not have.

3. It is possible that neither insurance company is paying out your benefits because they don’t have the other insurance policy information.

4. If these steps are not taken, both insurance companies MAY pay as if they are the only insurance policy resulting in overpayment which may take months to correct

5. IF THIS INFORMATION IS NOT PROVIDED PRIOR TO YOUR UPCOMING APPOINTMENT, WE WILL COLLECT OUT OF POCKET AND YOU WILL NEED TO SUBMIT YOUR OWN INSURANCE CLAIMS.

Patient Name(s):

Responsible Party:

Primary Insurance Company Name:

Primary Insurance Representative Name:

Primary Insurance Phone Call Reference Number:

Subscriber And Relationship To Child/Children:

Secondary Insurance Company Name:

Secondary Insurance Representative Name:

Secondary Insurance Phone Call Reference Number:

Subscriber And Relationship To Child/Children:

Third Insurance Company Name:

Third Insurance Representative Name:

Third Insurance Phone Call Reference Number:

Subscriber And Relationship To Child/Children:

Responsible Party Signature:

Draw your signature in the box below with your mouse or cursor.

Date: