1. The PATIENT(or the parent if the child is a minor) must sign at line # 1.

2. The holder of insurance (ie, the person who owns insurance) must sign at # 2.

3. Fill the section “Subscriber” (A)

a) Group plan # (# 3): this information is found on your insurance card, it can also be called a group number or policy (copy attached).

b) division number (# 4): enter only if your job involves a number of divisions.

c) certificate number or identity (# 5): this information is also on your insurance card (copy attached).

d) employer (# 6): insert name of your employer.

e) insurer (# 7): insert name of your insurance (company).

f) subscriber´s name (# 8): write the name of the person who owns the insurance.

g) date of birth (# 9): insert date of birth of the person who owns the insurance policy.

4. Fill the section “patient” (B): This section concerns the patient, that is to say his name, date of birth etc…

If you have any questions, please feel free to ask one of our receptionists who will be pleased to help you!

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