Submit and Update Your Contact I

YOUR ACCOUNT INFORMATION

Name of person completing this form:	*(Required)*

The following information is needed about the person financially responsible for this account. If you have dental insurance, the account should be set up under the name of the family member listed on the insurance policy as the insured member. If you have multiple insurance, such as in a family where husband and wife each have insurance coverage, please submit to us a separate Account Information Form for each.

FULL Name of Account Head or Insured Member: (name of person financially responsible for account)	*(Required)*
E-mail Address:
Street Address or Box Number:
City:
State:
Zip:

Home Phone Number:
Cell/Mobile Phone Number:
Work or Other Contact Phone Number:

The information below is required if you want us to submit insurance claims for you...
Social Security Number of Account Head (above):
Birth Date of Account Head (above):
Account Head (above) Marital Status:	Single Married Divorced Widowed Separated
Employer:
Employer's Mailing Address:
Employer's City:
Employer's State:
Employer's Zip:
Employer's Phone Number:

What is the name of your dental plan? This will be a plan name like State Employees Benefit Plan, Waterloo Hourly Wage Employees Plan, Wal*Mart Employees Plan, etc.

What is the name of the insurance company that manages your dental plan? This will be the name of an insurance company, like Prudential, Aetna, Metropolitan Life, Blue Cross of Arkansas, etc.
Group Number (if you have one):

Please type here any additional comments or information you need to send to us:

Before clicking the Submit Information button below, please note the following policies of our office: Medical Records and X-rays: All records we create, including x-rays, used in diagnosis and treatment of our patients are the property of this office. The fees you pay are for our time spent in your treatment, and for the expertise used in diagnosing and treating dental conditions. Payments you make are for complete dental services, not specific products. We are happy to transfer copies of our records to other healthcare professionals as needed, but original records must remain with us. Filing of insurance claims: We are very happy to handle the filing of dental insurance claim forms for our insured patients. Please be aware, though, that the insurance is yours, not ours. If your insurance company does not pay your dental bills, you will be expected to pay them yourself. If your insurance company unreasonably delays or refuses payment of your claim, we will ask you to please pay your bill in full, then deal with your insurance company yourself. We will be happy to furnish you with all the information needed to refile your claim.

Background music: Lipstick Traces from the album "Phenomenon" by UFO; composed by Michael Schenker.

Save time filling out forms when you visit our office. Use our online forms to send us your account and patient information.

When done submitting Account information, close this window to return to the information update page.

Just complete the Account Information form below and click the [Submit Information] button at the bottom of the page. Please fill out the form completely, since any information you don't submit here will probably need to be collected from you next time you're in our office.