Pediatric Dentistry of Winchester: Insurance Information Form

Pediatric Dentistry of Winchester: Insurance Information Form

Donna Klein, DMD | 2560 Bypass Road #2, Winchester, KY 40391
Dental Insurance Information
We need dental insurance information NOT your medical insurance information. They are different.
Are you covered under Kentucky Medicaid? If yes, please list your Medicaid ID number.*

NoYes
Are you covered under a dental insurance plan?*

YesNo
***We need your Dental Insurance information NOT your medical insurance information (they are different)***

Please attach a picture of your dental insurance card, if available.
Make sure the photo is in focus and not blurry.
FRONT of Dental Insurance Card
BACK of Dental Insurance Card
Policy Holder's Name*

First NameLast Name
Policy Holder's Date of Birth*

MonthDayYear
Date
Policy Holder's SSN#*
Policy Holder's Employer*
Dental Insurance Carrier*
Dental Insurance Phone Number*
Located on the back of card
ID / Member #*
Group #*
Are you covered by a secondary dental insurance plan?

YesNo
Only fill out the following information if you ARE covered by a secondary dental insurance plan.
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Holder's SSN#
Policy Holder's Employer
Dental Insurance Carrier
Dental Insurance Phone Number
Located on the back of card
ID / Member #
Group #
Should be Empty:

Dental Insurance Information