To Our Valued Patients:

 

Due to recent changes in the federal privacy policies, more and more insurance companies are unable to release details of your insurance coverage to our office. Therefore, we would require your assistance in obtaining this information. We have provided you with a list of questions to ask your insurance company. Please fill in or circle the information and return this to our office in person, by email or by fax (see contact info at bottom of this page).

 

Date:__________________

Group or Policy #____________________  ID or Certificate #_______________________

Name of Insured Member:_______________________________D.O.B._______________

Name of Insurance Company:_________________________________________________

Name of Employer:_________________________________________________________

Family members covered by this plan___________________________________________

 

1. What Fee Guide does your plan cover: Current ______   or Other______(year)

2. Is your plan on a Calendar Year: Yes or No

    If no, Benefit Year: From: (D/M/Y)________ to (D/M/Y)__________

3. Is there a deductible. No____     If Yes, Single$_____ Family$ ______

4. Basic treatment is covered at _____ % with a maximum of $______    or Unlimited max___

5. Major treatment is covered at _____% with a maximum of $______    or Unlimited max___

    Or No Major coverage _____

6. If the basic and major maximums are Combined , what is the combined limit $_________

7. Is there any coverage for Orthodontics: Yes or No

    If yes, covered at ____% with a maximum of $_____ per lifetime?___ Age limit?______

8. Please indicate 6, 9, 12, 24 or 36 month interval for each of the following:

    Recall Exam: ____months                                         Complete Exam: ____months

    Full Set of X-rays: ____months                                 Panoramic X-ray: ____months

    Bitewings X-rays: #_____ per ____months                  Polishing: ____months

    Fluoride: ____months and if there is any age limit? ____

9. Number of scaling units allowed ____

    per calendar year____ or per rolling 12 months____

10. Are Composite (white) Fillings allowed on molars (23321) Yes or No

11. Is there any coverage for Implants Yes or No

      If implants are not covered, does your plan have an alternate benefit clause? Yes or No

12. Endodontic treatment is covered at _____%

13. Can dental claims go electronically?  Yes or  No

 

We ask that you familiarize yourself with your insurance plan as we cannot be responsible for any procedures not covered by insurance. We can use the above information as a guide to answer any questions you might have but ultimately you are responsible for your own insurance information. If any of your insurance benefits change, we will require this information. If you change insurance companies or employers, a new form will be required to be filled out. Although we accept payment from your insurance company directly (when possible), all differences or nonpayments (from insurance) are the patient’s responsibility.

 

Patient or Guardian Signature   X________________________________________________

 

Thanks for your assistance!

 

Fax# 905-428-9291       Email: smile@pickeringvillagedental.com