Braces By DiMassa & Wenger 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.

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PRIMARY INSURANCE

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SECONDARY INSURANCE

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