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PATIENT INSURANCE BREAK-DOWN INQUIRY

DO I HAVE COVERAGE FOR THE FOLLOWING:

* Are you covered as of today? * New Patient Exam

*Are you covered as of today? * Panorex Xray

*Are you covered as of today? * Full Mouth Xrays

GENERAL POLICY INQUIRY:

FEE GUIDE YEAR: (Important to know)

IS YOUR PLAN ON A CALENDAR YEAR (Jan-Dec) OR A BENEFIT YEAR?

IS THERE A DEDUCTIBLE? $25 / $50 /$75 / $100 ? $

DENTAL YEARLY INSURANCE MAXIMUMS AND PERCENTAGES FOR:

ROUTINE TREATMENT: (cleanings, fillings, extractions etc.)

$
@
%

MAJOR TREATMENT: (Crowns, dentures,bridgework, implants etc.)

$
@
%

ORTHODONTIC TREATMENT

$
@
%

COMPOSITE (WHITE) FILLING COVERAGE ON MOLARS:

Example only : Proc #23322 TOOTH # 46 MO (SURFACE) –

DENTAL CLAIMS SUBMISSION:

Please, enter a valid value