Dental Insurance Form

Dental Insurance Form
Patient Name*

First NameLast Name
Policy Holder's Primary Dental Insurance Information

***We need your Dental Insurance information NOT your medical insurance information (they are different)***
Are you covered under a dental insurance plan?*

YesNo
Is the patient the dental insurance policy holder?*

YesNo
Please take a picture of your primary dental insurance card

Make sure the photo is in focus and not blurry.
Take Photo of Front of Primary Dental Insurance Card*
Take Photo of Back of Primary Dental Insurance Card*
Policy Holder's Name*

First NameLast Name
Policy Holder's Birth Date*

MonthDayYear
Date
Policy Holder's Employer*
Policy Holder's SSN#:*
Dental Insurance Carrier (if Delta or Blue Cross, please include of what state. Examples: Delta Dental of Iowa, BCBS of Texas)*
ID Number*
Group
Dental Insurance Phone Number
Located on Back of Card
Are you covered by a secondary dental insurance plan?*

YesNo