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A Smile 4 U - Jordan Diaz

Diaz date of birth

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Unformatted text preview: r: _Jordan L. Diaz ___________________________________________ Date of Birth: ______________ Social Security #: 674-44-3819 ________________ 03/02/2010 9993933 Member ID # on card: ________________________ Group #: 111896892731 _____________________ ________________ Employer Name and Address: _________________________________________________________________________________________ SELF Relationship to Patient: _____________________________________ Medicaid / Wellcare Name of Insurance Company: __________________________________ Telephone # of Insurance Company: (______) _______________ 877 232-8006 P.O. BOX 31224, Tampa, FL. 33631 Address to send Dental Claims: ________________________________________________________________________________________ AUTHORIZATION I understand that the information is correct to the best of my knowledge. I understand it will be held in the strictest of confidence and it is my responsibility to. I inform this office of changes in medical status. Child Consent: Jordan Lee Diaz I am the parent, guardian, or personal representative of ________________________________. And there are no court orders now in effect that prohibits me from signing this consent. I do hereby request and authorize the dental staff to perform necessary dental services for the child named above. Insurance Assignment and Release: Medicaid / Wellcare I certify that my dependent(s) is covered by insurance with ______________________________. And assign directly to A Smile 4U all insuranc...
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