Dental Insurance Information

Dental Insurance Information

Do you have dental insurance? If so, please fill this out. If you don't have dental insurance, you can skip this form :)
In order to provide the most accurate estimate for your child's dental treatment, please complete this form at least one week before your child's first visit so that we may verify your dental benefits.
Please select your dental insurance carrier from the list below.*
*Good News! Good life Smiles is in-network with all PPO plans of the dental insurance companies listed above! Please note that Good Life Smiles may not be in-network with DHMO plans. To verify our status with your dental insurance carrier, please visit your insurer's website or call the subscriber phone number on your insurance card.

If your insurance carrier wasn't listed above, we're still more than happy to submit a claim on your behalf for out-of-network carriers. Please be aware that your insurance carrier, whether in-network or out-of-network, may require a copay for visits!
Do you have a dental insurance card?
If yes, please upload photos of the front and back of your dental insurance card.
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Please fill out the information below.
Who is the policyholder for your dental insurance plan?*
(This is usually one of the grown-ups in your family.)
Policyholder's Date of Birth:*

MonthDayYear
If the dental insurance plan is through an employer, please list the employer below. If the plan is an individual plan, enter "individual."*
Subscriber ID/Member ID:*
(If a Subscriber ID is not listed, many insurance companies use the primary cardholder's social security number.)
Patient's Name: *
Have you verified that your kids eligible under your dental insurance plan?*
Please keep in mind that your dental insurance policy is a contract between you and your insurer. Being proactive in providing Good Life Smiles with the proper information and understanding your plan will help maximize your benefits to the full potential. It is your responsibility to verify plan benefits for services with your insurance company.

Please also be advised that financial responsibility on all accounts rests solely on the parent or legal guardian of the child. In the event that your insurance company disallows payment of a claim, the amount owed for your child's visit is your responsibilty.
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