Insurance Form

For those patients that wish to call insurance companies on their own or for those insurance companies that will not give the Dental office information due to privacy policies, the following form will guide you to ask specific questions that the Dental office needs to know to explain and help you understand your coverage. Once the form is filled, please submit it to our office and we will add it to your file.

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Policy holder Name

First

Last

Name of insurance company:

Policy (Group or plan contract) number

Policy Holder date of birth

Certificate (Identification) number:

Patient’s Full Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Upload Insurance Card (Front and Back)

If it is easier, leave the information blank below and just fill out the bare minimum; please attach a picture of your insurance information here, such an your insurance print out you were given or your insurance card, front and back.

Upload Secondary Insurance Card (Front and Back) (Optional)

Upload Digital Xrays (Optional)

Do you have any digital xrays you wish to share with our office from a previous dentist? Please attach here

Signature

Clear Signature

Captcha

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