Welcome to the Orthodontist

Westside Orthodontics Dental Insurance Form
In order to provide you the details of your orthodontic insurance benefits, please complete and return this form BEFORE the Exam/Consult appointment. If treatment is needed, we will present our treatment fee less than the estimated amount that insurance will pay and work out payment arrangements for the difference. If you have more than one insurance plan, please include information for both.

Please bring your Dental Insurance Card to the Exam appointment, or print one off of your insurance company's website.
Patient's Name*

FirstLast
Birthdate

MonthDayYear
Primary Insurance
Name
Birthdate

MonthDayYear
Date
Social Security Number
Employer Name
Name of Insurance Carrier
Insurance Phone Number

Area CodePhone Number
Group Name
Group Number ID
ID Number
"Mail Claims to" Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance
Name
Birthdate

MonthDayYear
Date
Social Security Number
Employer Name
Name of Insurance Carrier
Insurance Phone Number

Area CodePhone Number
Group Name
Group Number ID
ID Number
"Mail Claims to" Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: