| INSURANCE INFORMATION |
| MEDICAL & DENTAL INFORMATION |
Please bring copies of your medical and dental insurance ID card(s) and claim form(s)
with your portion of the forms completed so that we may submit them to your health
insurance carrier.
with your portion of the forms completed so that we may submit them to your health
insurance carrier.
Helath Insurance is constantly changing and can be very confusing. In order for you to maximize your
health benefits for anesthesia/sedation we are recommending that you contact:
a. your employee benefits person/department
b. your insurance carrier(s) (medical & dental)
health benefits for anesthesia/sedation we are recommending that you contact:
a. your employee benefits person/department
b. your insurance carrier(s) (medical & dental)
Some health plans require you to contact them and obtain approval prior to treatment.
| We recommend that patients speak with their primary care physician's office and request a letter of medical necessity for their anesthesia. Some carriers require a "medical necessity letter" for coverage. We will submit your physician's medical necessity letter with your medical insurance claim form. Please note the History & Physical Form has a section where your Doctor can denote "sedation/general anesthesia is a medical neccessity for the proposed dental treatment". |
1. Carrier:__________________________________________________
2. Claim Address:__________________________________________________
3. Insurance ID#:__________________________________________________
4. Group Number:_________________________________________________
5. Social Security #: _______________________________________________
6. Patient's Name: _________________________________________________
7. Date of Birth: ___________________________________________________
8. Relationship to Insured:__________________________________________
9. Name of Insured:________________________________________________
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