Dental Insurance form

Insurance Plan Information (please fill out another copy of this page if you have more than 1 insurance plan)

Insurance Company:

Subscriber Name:

Subscriber Birthdate:

Yearly $ Maximum:

Group Number:

Subscriber ID:

Benefits Year Ends:

Basic Coverage%:

Major Coverage%:

How often are examinations (check-ups) covered?

How often are Cleanings (scaling) covered?

How many units of scaling does your plan cover annually?

How often is polishing covered?

How often is fluoride covered?

Do you have coverage for Fluoride over 18 years of age?

I,, hereby authorize Dr. Sahra Kanji and any of persons under her employment to contact the insurance company outlined above in order to discuss the dental benefits on my behalf. The agent of the insurance company is hereby instructed to release any and all information with regards to, but not limited to: outstanding insurance claims, preauthorization, claim payment, and benefit eligibility as it applies to the policy outlined above. This release applies not only to me, the undersigned, but all members of my family covered under this insurance plan. This authorization will be effective from the date signed, until such time as the policy terminates. This written release will supersede any privacy policy in place by the insurance company as it applies to my dental health benefits.

Subscriber Signature:

Date:

Witness Signature:

Date: