Insurance fillable information form

For those patients that wish to call insurance companies on their own or for those insurance companies that will not give the Dental office information due to privacy policies, the following form will guide you to ask specific questions that the Dental office needs to know to explain and help you understand your coverage. Once the form is filled, please submit it to our office and we will add it to your file.

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Patient’s Full Name
Patient Home Address:
Max. file size: 64 MB.
Max. file size: 64 MB.

Coverage questions to ask:

Do I have coverage for specialists?

Below are codes to give the agent to check eligibility of frequency:


There are several types of exams that are performed often by the Dentist that your insurance may limit within a specific amount of time. They are as follows:


How often can I have the following exam procedure codes?

Other Common codes to ask eligibility for:

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