Do you have, or have you had, any of the following? (Check all that apply)
Personal Information/ All information is private and confidential
Please mark as you read each paragraph
You may not know this; dental insurance is an individual commodity. There are thousands of insurance companies and each company has thousands of individual group plans, each group plan is different from the next. There is no possible way a dental office would be able to know precise information about your dental plan. Dental offices are not directly connected to insurance companies, and now due to the privacy act (January 2004) most dental plans will not release information to the dental office. We must rely solely on our clients to give us the plan information. Some insurance companies will go so far as to only send the policy holder the information required by the dental office to submit your claims or for sending preauthorizations on your behalf.
Do you have Dental Insurance?
If yes, please provide the following information: Please note, we will not submit to any dental plan if we have not been given all the information requested. Also, there are a few dental plans that we will not accept assignment for: DIA, Healthy Kids, Ministry plans and Greenshield. However, we will do the paper work on your behalf.
Our office will deal with your dental insurance one of two ways
(Please be aware that there are some dental plans that we will only deal with “Non-Assignment” and some plans that are set up by your employer to be “Non-Assignment”)
*OPTION 2 ONLY AVAILABLE IF YOU ARE ABLE TO SUPPLY ALL NECESSARY INSURANCE AND CREDIT CARD INFORMATION!