• We are pleased to offer all our clients assignment of benefits; we direct bill your Insurance Provider on your behalf. Our goal is to maximize your Insurance benefits and make your dental visits as streamlined as possible. Your Insurance details are private and only made available to you and your employer. Insurance details are protected by the privacy act and we are not able to obtain any specific information. In order to better assist you better and provide you with accurate estimates/statements please inform us of the following:
  • Is there an Annual Deductible?
    If No, what year do they base their reimbursement on?
    If Rolling Year; when do your Insurance Benefits renew?
  • Please enter a number from 0 to 100.
  • Please enter a number from 0 to 100.
  • Please enter a number from 0 to 100.
    If Yes, my annual limit is:
  • If you are unable to answer any of these questions please call you Insurance Provider for a detailed breakdown of your benefit package using this form as a template. Please be aware that you are responsible for any portion that your Insurance Provider does not cover.

    If Assignment of Benefits does not appeal to you we do offer all our clients Non-Assignment. This is an exceptional option that appeals to many. If you would like to know the benefits of a Non-Assignment options please do not hesitate to ask.The security and privacy of your personal information is one of our primary concerns and we have taken every precaution to protect it.

    I have read and understand this information in its entirety: