Dental Insurance Verification Request

Please fill out the form below so that we can verify your dental insurance prior to your dental appointment. We are Preferred Providers with over 240 dental insurance companies and will happily verify and accept assignment to coordinate your dental insurance benefits and facilitate their payments for your dental care. We require at least 48 hours so that we can properly verify your dental insurance and reconfirm your benefits. Please fill out each section carefully and VERY ACCURATELY so that your benefits can be validated

    Patient First Name :

    Patient Last Name :

    Patient Date of Birth :

    Patient Social Security # or Patient ID # :

    Relationship to Insured :

    Contact E-mail :

    Please copy the above exactly as it appears on your Dental Insurance Card

    Insured/Subscriber First Name* :

    Insured/Subscriber Last Name* :

    Insured/Subscriber Date of Birth :

    Insured/Subscriber Social Security#:

    Insured/Subscriber ID # :

    Insured Group# :

    Exact Name of Dental Insurance Company* :

    Name of Employer :

    Please fill out each section carefully and VERY ACCURATELY so that your benefits can be validated.
    Attach a picture of both sides of your Dental Insurance Card

    Please upload a picture of the front of your Dental Insurance ID Card :

    Please upload a picture of the back of your Dental Insurance ID Card :

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    Please click "Submit" once and wait 30 seconds to process.