Jacobson & Tsou Dental Insurance Template

DENTAL INSURANCE FORM

DATE

For Office Use Only

PATIENT ACCT

Verified by:

Date Verified:

(Please fill out ALL highlighted information, it is necessary in order to request your insurance benefits from your insurance company.Without all of the proper information we will not be able to find out your dental benefits).

Patients Name

Date of Birth

PRIMARY INSURANCE INFORMATION

Insured Name (employee)

Date of Birth

Insured Address

Relationship to Patient

Name of Employer

Name of Insurance Co

Insurance Billing Address

Insurance Telephone

Group Number

Identification Number

Social Security Number

Office use: Phone

Online

Faxed

ORTHODONTIC BENEFITS

Lifetime Maximum amount:

Amount Used:

Amount Remaining:

Effective Date:

Waiting Period

Deductible: Yearly $

Percent %

Initial %

Payment Schedule:

If special

In Network

Out of Network

Payments to our office

Insured

Age Limit: Dependent

Student

Adult

SECONDARY INSURANCE INFORMATION

Insured Name (employee)

Date of Birth

Insured Address

Relationship to Patient

Name of Employer

Name of Insurance Co

Insurance Billing Address

Insurance Telephone

Group Number

Identification Number

Social Security Number

Office use: Phone

Online

Faxed

ORTHODONTIC BENEFITS

Lifetime Maximum amount:

Amount Used:

Amount Remaining:

Effective Date:

Deductible: Yearly $

Percent %

Initial %

Waiting Period

Payment Schedule:

If special

In Network

Out of Network

Payments to our office

Insured

Age Limit: Dependent

Student

Adult

Jacobson & Tsou Orthodontics

4200 W. PETERSON AVE.

CHICAGO, IL 60646

Office 773-545-5333

Fax 773-545-3636

281 W. Townline Rd.

Vernon Hills, IL 60061

Office 847-816-0633

Fax 847-816-0667