BDD INSURANCE FORM

DENTAL INSURANCE INFORMATION ONLY
DATE

MonthDayYear
Date
*As a courtesy to you, we accept assignment of insurance benefits from most insurance companies. HOWEVER, the balance is your responsibility whether your insurance company pays or not. You must make sure we have your current insurance information on file. Your insurance policy is a contract between you and your insurance company. We are not party to that contract.
Patient's Name*

First NameMiddle InitialLast Name
Preferred Name
Patient's Date of Birth*

MonthDayYear
Date
Age
PRIMARY ORTHODONTIC INSURANCE
Policy Holder's Name*

First NameMiddle InitialLast Name
SelfSpouseParentStep Parent
Policy Holder's Address*
City, State, Zip
Policy Holder's Soc. Sec. #*
Policy Holder's Date of Birth*

MonthDayYear
Date
Policy Holder's Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Policy Holder's Cell Phone
Format: (000) 000-0000.
Policy Holder's Work Phone
Format: (000) 000-0000.
Policy Holder's Employer*
Policy/Group#
Member ID#*
Insurance Company Name*
Effective Date of Coverage

MonthDayYear
Date
Insurance Co Provider Phone #
Format: (000) 000-0000.
Insurance Co Address
** I authorize release of any information relating to this claim.*
** I authorize payment directly to the dentist.*
SECONDARY ORTHODONTIC INSURANCE

If there isn't Secondary Coverage, please scroll down and Submit.
Policy Holder's Name

First NameMiddle InitialLast Name
SelfSpouseParentStep Parent
Policy Holder's Address
City, State, Zip
Policy Holder's Soc. Sec.#
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Holder's Home Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Policy Holder's Cell Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Policy Holder's Work Phone #:
Format: (000) 000-0000.
Policy Holder's Employer
Policy/Group#
Member ID#
Insurance Company
Effective Date of Coverage

MonthDayYear
Date
Insurance Co Address
Insurance Co Provider Phone #
Format: (000) 000-0000.
** I authorize release of any information relating to this claim.
** I authorize payment directly to the dentist.

Office Insurance Policy

Drs. Broderick, Dusek, and DeLeon
As a courtesy to our patients with active dental insurance plans, we will verify your eligibly prior to starting orthodontic service with our office. Our insurance department will validate the estimated insurance credit we have given to you is the most current information provided by your insurance policy.

Please know that insurance companies DO NOT pay for orthodontic treatment IN FULL upon submission of a single claim. Nor do they pay PER VISIT, as they do with your general dental needs. Orthodontic insurance is paid over the course of your treatment time, either monthly, quarterly, or annually depending on the policy.

In order to receive the full insurance benefit we have quoted for you, this policy MUST remain active for the duration of your orthodontic treatment with our office. If any changes or lapse in coverage occurs during the course of treatment, your insurance reserves the right to stop any additional payments on this treatment.

Please note that we only collect payment from one insurance carrier per orthodontic treatment. If you have dual coverages, we will delighted to file with your secondary payer on your behalf. However, we will require them to send any payments to you directly for your treatment. This clause also applies with coverages obtained after you have already started orthodontic treatment with our office. In addition, we only file insurance for patients in active orthodontic treatment. Insurance claims for lost or broken retainers will not be filed by our office.

If for any reason your insurance declines to pay the estimated portion of your orthodontic treatment, you are liable for the unpaid balance prior to the removal of your orthodontic appliances.
Name of Responsible Party*

First NameLast Name
Please sign below if you have read the above paragraph carefully and you understand our Office Insurance Policy. *
Date

MonthDayYear
Date
Should be Empty:

DENTAL INSURANCE INFORMATION ONLY

PRIMARY ORTHODONTIC INSURANCE

SECONDARY ORTHODONTIC INSURANCE

Office Insurance Policy