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

We are unable to submit medical claims to:

TRICARE, BCBS FEDERAL PLANS, KAISER AND PROVIDENCE

Please contact our office if you have any questions.

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 Information: Medical Insurance (not Dental)
Medical Insurance Company Name*
Insurance Company Phone Number*
Claims Mailing Address
("submit claims to..." on back of insurance card)
Note: Please leave blank for Blue Cross Blue Shield, Regence, and Premera plans

Address City State / Province / Region ZIP / Postal Code
Subscriber ID Number*
Plan/Group Number*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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)