DENTAL INSURANCE FORM

(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).


PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION
(if applicable)

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