Insurance Plan Information (please fill out another copy of this page if you have more than 1 insurance plan)
Yearly $ Maximum:
Benefits Year Ends:
0% 50% 80% 100% other
How often are examinations (check-ups) covered?
6 months 9 months 12 monthsother
How often are Cleanings (scaling) covered?
6 months9 months12 monthsother
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?