Dear Sir / Madam, We would like you to know that we are a fee for service practice that does not participate in any insurance plans. However, as a courtesy to you we could print and mail insurance forms on your behalf. Additionally, we would be glad to include a narrative report, radiograph(s), and/or photograph(s) if required.

As a fee for service practice, we do not have provider numbers with the dental insurance companies. This means that we do not have access to follow up on your claims and you will need to contact your insurance provider directly as necessary.

Please provide your insurance card (to make a copy for our records) and fill out the following information:

Dental insurance company

Dental Claims Address

Name of Insured

Date of Birth of Insured

Social Security # of Insured

Insurance group/policy #

Self-insured

Yes

If not, name of employer or institution that provides insurance