Dental Insurance Verification printable pdf download

Dental Insurance Verification

If you have a card with information about your insurance carrier please feel free to send us a copy of the

front and the back of the card, or you may fill in the blanks below and forward this back to our office.

Policy holder Employer: ___________________________________________

Policy holder name: ______________________________________________

Policy holder date of birth: _________________________________________

Policy holder SSN*/or Member ID #: ______________________________________________

*in some cases the SSN of the policy holder is the member identification number for your insurance carrier (you may look at your card for other

personalized pieces of information such as an ID #)

* If you are uncomfortable providing this information via fax or e-mail you may contact our office directly and give this information to Lisa, our

insurance benefits coordinator.

Patient Name*: ________________________________________________

* If patient is same as policy holder, leave this section blank.

Patient date of birth: _____________________________________________

Name of Dental Insurance Company: __________________________________

Customer Service number for Insurance: ________________________________

** If you need assistance completing this form please contact our office via phone, fax or email.

City Dental

1716 Kenilworth Ave. Ste 180

Charlotte, NC 28203

Phone: 980-207-4437

Fax: 980-207-4878

Email:

Dental Insurance Verification