Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Oral Surgery Billing Authorization Form
Patient Full Name *
Date of Birth
____ / ____ / ________
Primary Insurance Information
Carrier
Member ID
Group number
Subscriber name
Scheduled Procedure
Estimated Procedure Cost
Payment Method
- Credit or debit card
- Bank transfer
- Cash
- Check
- Other
Financial Responsibility Agreement
Your practice's consent wording goes here.
Signature
Date
Authorization Signature
Date
Oral Surgery Billing Authorization Form template from formisoft.com. formisoft.com/intake-templates/oral-surgery-billing-authorization