ABLE FAMILY DENTAL PATIENT INSURANCE COVERAGE INFORMATION

PATIENT INSURANCE COVERAGE INFORMATION

To ensure the accuracy of our records, we ask that you complete this patient insurance coverage information form.
Patient Name:*

First NameLast Name
Date:

MonthDayYear
Insurance Company:
Policy Holder Name:
Date of Birth:

MonthDayYear
Group of Policy #:
Certificate or ID #:
Email:*
example@example.com
DENTAL COVERAGE DETAILS
What is your annual maximum?
(Calendar or benefit year)
What is your deductible?
(co-pay)
What is your percentage of coverage?
INSURANCE BREAKDOWN

How often are you eligible to have the following services?
Examination:
Complete 01103:
Recall 01202:
X-rays:
Preventative:
Root planing (units):
Sealants:
Desensitizing:
Fee guide year coverage is based on:
Please upload a picture of your insurance card here:

Uploading images of your card now will help speed up the check-in process for your next visit.
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PLEASE READ:

Benefit coverage is a contract between yourself, the insurance company, and your employer (where applicable). We are happy to assist you with any questions you may encounter, but the specifics of your plan are not always available to us. It is important that you know your insurance coverage. Many insurance companies use previous years fee guide to base their payments on, which results in a patient portion owing. It is your responsibility to pay any portion not covered by your insurance plan. We require payment in full for all treatment rendered before leaving our office.
Please initial here that you have read the above*

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PATIENT INSURANCE COVERAGE INFORMATION

DENTAL COVERAGE DETAILS

INSURANCE BREAKDOWN