• Insurance Intake Form

    ONE Insurance Intake Form for EACH dental insurance plan.

  • For the best experience, please take a moment to read these tips.

     

    Please read each question on this form carefully and respond accurately.

    If the form is not completed accurately; we may ask you to complete this form again.

  • Please submit ONE Insurance Intake Form for EACH dental insurance plan.  

    We do not accept Insurance Intake Forms that include two or more insurance plans on the same form.

    You may include multiple family members on the same Insurance Intake Form if they are patients of Dr. Tsintolas and covered und the same insurance plan. 

  • Even if you believe you do not have orthodontic benefits, please submit your DENTAL plan information. 

    Some services may be covered under dental rather than orthodontic benefits.
  • BEFORE YOU BEGIN... have ready your physical insurance card OR virtual insurance card OR online insurance account OR insurance details.
  • If you do not have your DENTAL insurance details.... please contact your DENTAL insurance provider, employer, group administrator, or online insurance account.

  • We prefer a photo upload of the front and back of your DENTAL insurance card or screenshots of your digital DENTAL card.

    If you don't have access to a physical or digitial card, our prompts will guide you through collecting the required information.

  • Please double-check that you are uploading your DENTAL insurance card and referencing your DENTAL plan information on this form.

    Most DENTAL insurance providers supply a physical or digitial insurance card.

    A very small number of MEDICAL insurance providers include the DENTAL insurance provider information on the same card.  If you do not have a separate DENTAL insurance card, please upload your MEDICAL insurance card only if it includes your DENTAL plan information.

    Please do not submit a MEDICAL card that does not reference your DENTAL plan.  MEDICAL insurance plans do not provide coverage for dental or orthodontic services rendered by our office, and we are unable to determine DENTAL insruance beneitis from a MEDICAL insurance card alone.

    Please, do not upload your PRESCRIPTION card, as it does not contain DENTAL insurance information. 

  • Unfortunately, we cannot research benefits for a plan that is not yet active. 

    When your plan is active, submit this form to share the plan details with us.                                               

  • While completing this form, do NOT navigate back to the previous page- doing so will corrupt your form.

    Click the NEXT button to proceed only after verifying that your responses on the current page are accurate.

  • DENTAL Insurance Information

    Do not submit your MEDICAL plan details unless, in rare circumstances, we ask you to do so.

  • Before you begin, we'd like to point out that the SUBSCRIBER / MEMBER / POLICYHOLDER is the employee or the primary insured person on the DENTAL plan. This person is neither the spouse nor a dependent of the SUBSCRIBER / MEMBER / POLICYHOLDER.

  • If your DENTAL insurance provider is listed below, select it. OTHERWISE select OTHER and enter the name of your DENTAL insurance provider. NOTE: Dr. Tsintolas participates with most insurance providers and he is in-network with FAR MORE INSURANCE PROVIDERS THAN THE VERY FEW LISTED HERE.*
  • Through which entity are you insured?
  • What is the effective date? [When did coverage begin?]*
     / /
  • What is the status of the DENTAL insurance plan?*
  • Please advise the date the insurance plan will terminate. Please use the COMMENTS box at the end of this form to advise if and when new insurance is coming on board. We cannot research benefits until the patient is enrolled in the anticipated plan.*
     / /
  • Your physical or digital insurance card provides the best information for our research and claim submissions.*

  • DO NOT navigate backwards.  Please review your responses on this page for accuracy and then click the NEXT button to proceed.

  • Upload Photos

  • Please provide TWO photos, one of the FRONT of the physical or digital insurance card and the other of the BACK.

    Screenshots of online insurance details will suffice if the information is equivalent to a physical or digital card.

    The accepted image file formats are .jpg, .jpeg, and .png.

    Click inside the first box below.  Follow the prompts offered by your computer or device and upload a photo of the FRONT of the physical or digital insurance card.  Repeat in the second box to upload a photo of the BACK of the physical or digital insurance card.

    All text in your photos must be VISIBLE, IN FOCUS, FREE OF GLARE, and EASY TO READ.  If we cannot read the text, we will ask you to submit this form again with photos of satisfactory quality.

    TIP: Granting access to your camera in your device settings or permissions may be necessary.

    TIP:  If the uploaded photo is unsatisfactory, click the trashcan icon to delete it.  Then, upload another photo.

    TIP:  Convert a .pdf document to .jpg, .jpeg, or .png by taking a photo or capturing a screenshot of the .pdf document. 

  • FRONT OF CARD
    Drag and drop files here
    Choose a file
    Cancelof
  • BACK OF CARD
    Drag and drop files here
    Choose a file
    Cancelof

  • DO NOT navigate backwards.  Please review your responses on this page for accuracy and then click the NEXT button to proceed.

  • Insurance Details

  • Please respond to the prompts and provide your insurance details.

    If you don't know your insurance details, please contact your employer or group insurance manager.  Another source of information is your online insurance member account.

    Failing to respond and/or responding with incorrect information will delay our research of your insurance plan and may result in the need to resubmit this form and/or rescheduling a pending consultation or visit.  Responses are required for all fields.

  • Format: 000-000-0000.

  • DO NOT navigate backwards.  Please review your responses on this page for accuracy and then click the NEXT button to proceed.

  • Subscriber / Member / Policyholder Information

    Please read this IMPORTANT note carefully. The SUBSCRIBER / MEMBER / POLICYHOLDER is the employee or the primary insured person on the DENTAL plan. This person is neither the spouse nor a dependent of the SUBSCRIBER / MEMBER / POLICYHOLDER. Please provide the SUBSCRIBER / MEMBER / POLICYHOLDER information on this page to avoid needing to submit a corrected form.
  • What is the SUBSCRIBER / MEMBER / POLICYHOLDER'S suffix, exactly as it appears on the DENTAL insurance plan?*
  • What is the SUBSCRIBER / MEMBER / POLICYHOLDER'S date of birth?*
     / /
  • Is the SUBSCRIBER / MEMBER / POLICYHOLDER also the patient?*

  • DO NOT navigate backwards.  Please review your responses on this page for accuracy and then click the NEXT button to proceed.

  • Subscriber / Member / Policyholder Information- continued

  • You indicated the SUBSCRIBER / MEMBER / POLICYHOLDER is also the patient.

  • What is the PATIENT'S suffix, exactly as it appears on the DENTAL insurance plan?
  • What is the PATIENT's date of birth?
     / /
  • What is the PATIENT'S relationship to the SUBSCRIBER / MEMBER / POLICYHOLDER?
  • Is there a second family member enrolled in this DENTAL plan who is either a patient of Dr. Tsintolas or consulting with Dr. Tsintolas? (Hover for more details.)*

  • Patient #1 Information

  • What is the PATIENT'S suffix on record with the DENTAL insurance plan?*
  • What is the PATIENT's date of birth?*
     / /
  • What is the PATIENT'S relationship to the SUBSCRIBER?*
  • Is there a second family member enrolled in this DENTAL plan who is either a patient of Dr. Tsintolas or consulting with Dr. Tsintolas? (Hover for more details.)*

  • Please review your responses on this page for accuracy and then click the NEXT button to proceed.

  • Patient #2 Information

  • What is the PATIENT'S suffix on record with the DENTAL insurance plan?*
  • What is the PATIENT's date of birth?*
     / /
  • What is the PATIENT'S relationship to the SUBSCRIBER?*
  • Is there a third family member enrolled in this DENTAL plan who is either a patient of Dr. Tsintolas or consulting with Dr. Tsintolas? (Hover for more details.)*

  • DO NOT navigate backwards.  Please review your responses on this page for accuracy and then click the NEXT button to proceed.

  • Patient #3 Information

  • What is the PATIENT'S suffix on record with the DENTAL insurance plan?*
  • What is the PATIENT's date of birth?*
     / /
  • What is the PATIENT'S relationship to the SUBSCRIBER?*
  • Is there a fourth family member enrolled in this DENTAL plan who is either a patient of Dr. Tsintolas or consulting with Dr. Tsintolas? (Hover for more details.)*

  • Patient #4 Information

  • What is the PATIENT'S suffix on record with the DENTAL insurance plan?*
  • What is the PATIENT's date of birth?*
     / /
  • What is the PATIENT'S relationship to the SUBSCRIBER?*
  • Is there a fifth family member enrolled in this DENTAL plan who is either a patient of Dr. Tsintolas or consulting with Dr. Tsintolas? (Hover for more details.)*

  • Patient #5 Information

  • What is the PATIENT'S suffix on record with the DENTAL insurance plan?*
  • What is the PATIENT's date of birth?*
     / /
  • What is the PATIENT'S relationship to the SUBSCRIBER?*

  • Information About the Person Completing this Form

  • Format: 000-000-0000.
  • What type of phone number did you provide?*

  • 0/150
  • Date*
     / /

  • By clicking SUBMIT, the subscriber authorizes Dr. Tsintolas' practice to verify insurance benefit eligibility; submit, pursue, and manage insurance claims; communicate with insurance carriers and representatives, and disclose protected health information to the insurance provider and any third parties as necessary for claim adjudication and payment.

    By clicking SUBMIT, the subscriber acknowledges the following:  Our office makes reasonable efforts to obtain accurate benefit information; however, insurance providers do not guarantee the accuracy of coverage representations.  Accordingly, our office is not responsible for inaccuracies provided by the insurance carrier or for your reliance on such information.

    If the SUBMIT button is unresponsive, there are one or more unanswered fields on THIS FINAL PAGE.  Respond to the unanswered questions on THIS FINAL PAGE before clicking SUBMIT again.  Do not navigate back to a previous page, as this will corrupt your form and require a new submission.

    Upon clicking SUBMIT, your Insurance Intake will be sent to Dr. Chris Tsintolas, a confirmation screen will appear, and you will receive a confirmation email.

    We sincerely appreciate your time and effort in completing this form. Thank you!

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