West Kelowna Dentist | Insurance Form

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:

Name*

First Last

Insurance Provider is:

Policy Holder Name:

Policy Holder DOB:

Employer of Policy Holder:

Group Plan/Policy Number:

Division Number:

Certificate Number or ID Number:

Your Dependant Number Is:

Is there an Annual Deductible?

If yes, what is the dollar amount? Per person $

Per family $

Does your Insurance Provider use the Current Free Guide?

Yes
No

If No, what year do they base their reimbursement on?

Are your Insurance Benefits based on a Calendar Year or a Rolling Year?

Calendar Year
Rolling Year

If Rolling Year; when do your Insurance Benefits renew?

Basic Coverage Percentage:

Please enter a number from 0 to 100.

Annual Maximum:

Major Coverage Percentage:

Please enter a number from 0 to 100.

Annual Maximum:

Combined annual maximum for Basic and Major?

Orthodontic Coverage Percentage:

Please enter a number from 0 to 100.

Lifetime Maximum:

Age Limit:

Does your Insurance Provider allow Composite Fillings to be covered on molars?

Yes
No

Your Insurance Provider allows Recall Exams every ( ex. every 6 months, 2x per year, 9 months, 1 year:

Your Insurance Provider allows Prophy Polishes every:

Your Insurance Provider allows Fluoride every:

Is there an age limit:

Your Insurance Provider covers units of Scaling: #

Your Insurance Provider covers how many units of Root Planning:

Your Insurance Provider allows a Panoramic Radiograph every:

Your Insurance Provider allows Bitewing Radiographs every:

Does your Insurance Provider have an annual limitation for Radiographs?

Yes
No

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:

Date

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