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Personalized Dental Care For Your Entire Family

                                            First Avenue Dental
                                        Insurance Information Form

(Please fill in your information and bring to your appointment if you have not already done so.)

We will always do our best to maximize insurance coverage for you, but it is important that you are aware of the following:

1. Currently, insurance companies do not cover 100% of recommended treatment. Insurance can certainly help but every policy has limitations.
2. We work with over 100 insurance companies and they all have different sets of rules and criteria. We will always diagnose you based on your mouth…what we feel is in your best interest, not based on which insurance company you have.
3. Since insurance companies vary, to be fair, we have to ask that all patients are ultimately responsible for their bill regardless of their particular insurance company’s coverage.
4. We do our best to estimate insurance coverage but again policies do vary. We ask that you pay your estimated portion at the time of service, your co-pay is expected at the time of service.

Signature __________________________________________Date __________________
Name of Insured____________________________________________________________________

Relationship to Patient________________Birthdate_______________SS#___________

Name of Employer _________________________Work Phone_____________________

Insurance Company ________________________ Group # ________________________
Ins Co. Address ____________________________________________________________

Secondary Insurance _______________________________________________________

Name of Insured________________________Birthdate______________SS#__________

Name of Employer __________________________Work Phone____________________

Address of Employer_______________________________________________________

Insurance Company ___________________________Group # ______________________

Ins Co. Address_____________________________________________________________

Name of College, if attending_______________________________________________
 

Phone:  320-632-8113

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Last modified: 02/15/08                                                < >