Dental Insurance Claim
Coordination of Benefits Form
Patient Information
Full Name
Date of Birth
Patient ID/Member #
Subscriber Name
Relationship to Subscriber
Self
Spouse
Child
Other
Primary Insurance Information
Insurance Company Name
Group #
Policy #
Effective Date
Termination Date
Secondary Insurance Information
Insurance Company Name
Group #
Policy #
Effective Date
Termination Date
Other Coverage Information
Is patient covered by another dental plan?
Yes
No
If yes, provide details
Signature & Authorization
Signature
Date