Patient Form

Assignment of Benefits & Insurance Authorization

Authorize Valley Dental Care to file claims and receive insurance benefits on your behalf.

Please do not include emergency medical information in this form. If you are experiencing a life-threatening emergency, call 911.

Select office *

ZIP code

Patient

First name *

Last name *

Insurance company

Member ID

Authorization

I assign my dental insurance benefits to be paid directly to Valley Dental Care. *

I authorize Valley Dental Care to file insurance claims on my behalf. *

I authorize the release of information necessary to process my dental claims to my insurance company. *

I understand I remain responsible for any balance not paid by my insurance. *

Electronic signature

By typing my name below, I understand and agree that this electronic signature has the same effect as my handwritten signature.

Typed full legal name *

Date

I confirm this is my electronic signature and the information I provided is accurate.

By submitting this form, I understand that Valley Dental Care will use this information to contact me and prepare for my dental visit. See our Privacy Policy and Terms of Use.