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?
Is the patient the dental insurance policy holder?
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 CardFormat: (000) 000-0000.
Are you covered by a secondary dental insurance plan?
- Is the patient the dental insurance policy holder?
- Take Photo of Front of Secondary Dental Insurance Card
- Take Photo of Back of Secondary Dental Insurance Card
- Policy Holder's Name
  
  First NameLast Name
- Policy Holder's Birth Date
  
  MonthDayYear
  Date
- Policy Holder's SSN#:
- Policy Holder's Employer
- Dental Insurance Carrier
- Dental Insurance Phone Number
  Located on Back of CardFormat: (000) 000-0000.
- ID Member
- Group
- Should be Empty: