BEST LIFE and Health Insurance Company PO. Box …

MEMBER COMPLETE1 Patient s name 2 Relationship to member3 Patient s birthday 4 If full-time student name of school? 5 Member name First Middle initial Last6 Member social security number7 Address 8 City State Zip9 Phone number10 Marital Status11 Is member or spouse covered by another dental plan Yes No12 Name and address of other Insurance Company 13 Spouse s date of birth14 Name of spouse s employer 15 ID number16 Spouse s social security number 17 If injured how and where did accident happen? 18 Did accident happen at work? Yes No19 Date of accident I hereby accept the treatment plan specified below and authorize my dentist to release any and all medical information including dental information to the above named administrator for purposes of claims administration and evaluation utilization, review and financial audit.

Arizona: For your protection, Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal

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