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Justin R. Dillner, D.D.S.INSURANCE VERIFICATION FORM PATIENT INFORMATION Patient Name:Social Security Number:Birthdate:Relationship to Subscriber:SUBSCRIBER INFORMATION Subscriber Name:Social Security.

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Subscriber: The individual who signs and is responsible for a contract with a health insurance plan. The subscriber is the person subcribing to the insurance plan for the patient case. The subscriber is different from the enrollee, who is defined as anyone covered under the contract.

Relationship to applicant means what is your relationship with the applicant. If you are father of your applicant then relationship is the son.

As mentioned earlier, the 'insurer' is the one calculating risks, providing insurance policies, and paying out claims. The 'insured,' on the other hand, is the person (or people) covered under the insurance policy.

§ 404.354 Your relationship to the insured. You may be related to the insured person in one of several ways and be entitled to benefits as his or her child, i.e., as a natural child, legally adopted child, stepchild, grandchild, stepgrandchild, or equitably adopted child.

The guarantor is customarily the person bringing the patient in for treatment. This person is not necessarily the same as the subscriber.

Paper Claim Submitters - Patient relationship to insured should be reported in box 6 on CMS1500 for professional claims.

The guarantor is always the patient, unless the patient is a minor or an incapacitated adult. The guarantor is not the insurance subscriber, the husband, or the head of household. ... College students 18 years of age or older are always the guarantor for services they receive.

Definition: Code indicating the relationship between two individuals or entities.

Relationship to you: Connection by blood or marriage; kinship. Relationship with you: A particular type of connection existing between people related to or having dealings with each other.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232