Insurance Form

Please bring in any of your insurance (Medicaid, DSHS, Medical, Dental) cards into the dental office/surgery center on the day of surgery. We will make a copy of them for billing purposes.

Download M2 Anesthesia Insurance Form

M2 Anesthesia is not contracted with any medical commercial insurance companies. As a courtesy, we will submit a claim to your medical insurance carrier on your behalf. However, we are unable to submit claims to the following companies: TRICARE, BCBS FEDERAL PLANS, KAISER AND PROVIDENCE.

For more information on commercial insurance, Medicaid, or our self-pay rates, please click here or contact our office.

If you would like us to submit a courtesy claim to your commercial insurance carrier, please complete the form below. As a reminder, we cannot submit claims to TRICARE, BCBS FEDERAL PLANS, KAISER AND PROVIDENCE. This information will be emailed directly to M2 Anesthesia’s business office and we will contact you with any questions or if we need more information.

PLEASE FILL OUT THE MEDICAL INSURANCE INFORMATION PAGE

AND IT WILL BE EMAILED DIRECTLY TO M2 ANESTHESIA. WE WILL CONTACT YOU IF WE HAVE ANY QUESTIONS OR NEED MORE INFORMATION.

Download M2 Anesthesia Insurance Form

1Service/Patient Info

2Insurance Information: Subscriber

3Insurance Information: Medical Insurance

Date of Service*
MM slash DD slash YYYY
Place of Service / Dentist*
Patient Info
Patient Name*
First Name Last Name
Patient Birthdate*

Save and Continue Later

Insurance Subscriber Information
Name*
First Name Last Name
Birthdate*
Home Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*

Save and Continue Later

Insurance Form

PLEASE FILL OUT THE MEDICAL INSURANCE INFORMATION PAGE

Patient Info

Insurance Subscriber Information

Insurance Information: Medical Insurance (not Dental)