This form is designed to help get the patient reimbursed for the services performed. Since each insurance company is different, we cannot guarantee a specific amount to be reimbursed. The referring doctor is responsible for completing the required information on form. Please complete the top part of the form if the patient DOES NOT HAVE dental insurance, and the bottom part of the form if the patient DOES HAVE dental insurance. The referring doctor should review the output sent to him or her, and check off the appropriate boxes associated with the views received. It is the patient?s responsibility to submit the insurance form to the insurance company along with a copy of the receipt. Please download the acrobat version of this file at the bottom of this page so you can print and copy them at your leisure.
(Form is to be completed by the referring doctor.)