Implant Dentistry Centre | Payment Info Form

You may fill out and print these forms before your first visit: Patient Info | Payment Info

Payment Information - Please fill out and print this form
Chart / Code #
Name
Address
City, State, Zip
Home Phone
Work Phone
Method of Payment: Payment is appreciated and expected at the time of service. We accept cash, check, Master Card, American Express and Visa.
Dental Insurance Policy Holder Information
FIRST:
Insurance Company Name
Address claim to:
City, State, Zip
Phone
Group Name or Number
Employer
City, State, Zip
Subscriber's Name
Subscriber's SSN
Subscriber's Date of Birth
SECOND:
Insurance Company Name
Address claim to:
City, State, Zip
Phone
Group Name or Number
Employer
City, State, Zip
Subscriber's Name
Subscriber's SSN
Subscriber's Date of Birth
Release and Assignment:
I hereby authorize the release of any information, including diagnosis and the records of any treatment or examinations rendered, to my insurance company. This release is soley for the facilitating the billing and reimbursement, directly to the doctor of insurance benefit under which I am entitled. I understand that payment is due on the day of my treatment and that a finance charge of 1.5% per month will be charged. Signed: Date: - -

Implant Dentistry Centre at The Bicon Building
501 Arborway
Jamaica Plain, MA 02130

tel (617) 524-3900
fax (617) 390-0043

Payment Information - Please fill out and print this form