Insurance Intake Form

Insurance Intake Form

ONE Insurance Intake Form for EACH dental insurance plan.

For the best experience, please read these tips.

ONE Insurance Intake Form for EACH dental insurance plan.

We reject Insurance Intake Forms that include two or more insurance plans.

This form is intended to gather insurance information only for individuals who are patients of Dr. Tsintolas or those consulting with Dr. Tsintolas. Do not include family members who are neither patients nor consulting with Dr. Tsintolas.

You may include all relevant family members covered under the same DENTAL plan on a single Insurance Intake form. However, you must complete a separate Insurance Intake Form for each DENTAL plan.

We require your DENTAL plan information, even if you believe you do not have orthodontic benefits.

Some services may be covered under dental rather than orthodontic benefits. We will research your plan for potential benefits.

Please ensure you're providing your DENTAL plan details, not your MEDICAL plan information.

MEDICAL insurance does not cover orthodontic care. (In rare circumstances, we may need your MEDICAL insurance information. If this is the case, we will specifically direct you to provide it.)

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

Let us know when you are enrolled and your plan is active.

BEFORE YOU BEGIN... have ready your physical insurance card OR virtual insurance card OR online insurance account OR insurance details.

When possible, we prefer a photo upload of the front and back of your DENTAL insurance card or screenshots of your virtual DENTAL card.

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

If you do not have your DENTAL insurance details.... you can obtain your DENTAL insurance details from your insurance provider, employer, group administrator, and online insurance account.

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.

Please take the time to read the tips on this page. Please read each question on this form carefully and respond accurately.

A form submission with missing or inaccurate information can cause delays.

We will follow up by email, text, or phone if there are issues; we may ask you to complete this form again.

Upload Photos
Please provide TWO photos, one of the FRONT of the physical or virtual insurance card and the other of the BACK.

Screenshots of online insurance details will suffice if the information is equivalent to a physical or virtual 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 virtual insurance card. Repeat in the second box to upload a photo of the BACK of the physical or virtual 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.
Check your image- is it the FRONT of the card? Is the text in focus?
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Check your image- is it the BACK of the card? Is the text in focus?
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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.
You indicated your insurance provider DOES NOT furnish the subscriber with an insurance card.
What is the insurance provider's dedicated phone number for DENTAL professionals? If none, enter the phone number for dental benefits, eligibity, and/or claim inquiries. *
Please enter a valid phone number.Format: 000-000-0000.
Your DENTAL insurance company should provide a DENTAL claim mailing address. Otherwise, it should provide a claim mailing address or a physical address. (Do not enter the SUBSCRIBER / MEMBER / POLICYHOLDER or patient home address.)*

Street Address

Street Address Line 2

CityState

Zip Code
What is the SUBSCRIBER / MEMBER / POLICYHOLDER ID number?*
Enter the SUBSCRIBER / MEMBER / POLICYHOLDER ID NUMBER.
What is the GROUP NUMBER? (MetLife TIP: MetLife may refer to the Group Number as the Customer Number.)*
Enter the GROUP NUMBER.
What is the POLICY NUMBER? Some plans do not have a POLICY NUMBER, in which case enter NONE.*
Enter the POLICY NUMBER.
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 first name, exactly as it appears on the DENTAL insurance plan? *
First name of the SUBSCRIBER / MEMBER / POLICYHOLDER.
What is the SUBSCRIBER / MEMBER / POLICYHOLDER'S middle name / initial, exactly as it appears on the DENTAL insurance plan? If none, enter NONE.*
Middle name / initial of the SUBSCRIBER / MEMBER / POLICYHOLDER.
*What is the SUBSCRIBER / MEMBER / POLICYHOLDER'S last name on record with the DENTAL insurance plan?*
Last name of the SUBSCRIBER / MEMBER / POLICYHOLDER.
no suffixIIIIIIVVJr.Sr.
What is the SUBSCRIBER / MEMBER / POLICYHOLDER'S date of birth?*

MonthDay Year
Date of birth of the SUBSCRIBER / MEMBER / POLICYHOLDER.
Yes, the SUBSCRIBER / MEMBER / POLICYHOLDER is also the patient.No, the SUBSCRIBER / MEMBER / POLICYHOLDER is not the patient.
DO NOT navigate backwards. Please review your responses on this page for accuracy and then click the NEXT button to proceed.

Information About the Person Completing this Form
Please provide your phone number so we can reach you should we have questions.*
Please enter a valid phone number. We call, leave messages, and send texts. We do not share contact information. Format: 000-000-0000.
homecell
Please provide an email address to receive a confirmation of form submission.*

Confirmation EmailWe do not share contact information.
Please provide your name- the person completing this form.*

First NameLast Name
(optional) Your notes, additional information, and details about anticipated new insurance.

0/150
Date*

MonthDayYear
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!
Should be Empty:

Insurance Intake Form

DENTAL Insurance Information

Upload Photos

Insurance Details

Subscriber / Member / Policyholder Information

Subscriber / Member / Policyholder Information- continued

Patient #1 Information

Patient #2 Information

Patient #3 Information

Patient #4 Information

Patient #5 Information

Information About the Person Completing this Form