Insurance Verification Online Form

As a service to our patients, we will file your dental insurance. However, you are responsible for all communication with your insurance company except for additional information required of this office pertaining to specific procedures. Please fill out this form for your New Patient Appointment. Also, please understand that dental insurance is intended to cover some, but not all, of the cost of your dental care, and may include a deductible, which might need to be collected at your appointment.

Insurance Verification Form

* Indicates required field

Patient First Name *

Patient Middle Name *

Patient Last Name *

Policy Holder's First Name *

Policy Holder's Middle Name *

Policy Holder's Last Name *

Relationship to Patient *

Policy Holder's Date of Birth *

Social Security Number *

Policy Holder's Employer *

Dental Insurance Company *

Group Number *

Member Number *

I certify that I am covered by the dental insurance company which I listed above and I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submission, whether manual of electronic. *

Yes No

Submit