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Westside Orthodontics Dental Insurance Form
In order to provide you the details of your orthodontic insurance benefits, please complete and return this form BEFORE the Exam/Consult appointment. If treatment is needed, we will present our treatment fee less the estimated amount that insurance will pay and workout payment arrangements for the difference. If you have more than one insurance plan, please include information for both.
Please bring your Dental Insurance Card to the Exam appointment, or print one off of your insurance company's website.
Patient First Name
*
Patient Last Name
*
Birthdate (mm/dd/yyyy)
*
+
PRIMARY INSURANCE
First Name
Last Name
Birthdate (mm/dd/yyyy)
+
Social Security Number
Employer
Name of Insurance Carrier
Group Name
Group Number
ID Number
"Mail Claims to" address
Insurance Phone Number
SECONDARY INSURANCE
First Name
Last Name
Birthdate (mm/dd/yyyy)
+
Social Security Number
Employer
Name of Insurance Carrier
Group Name
Group Number
ID Number
"Mail Claims to" address
Insurance Phone Number
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