Dental Insurance Verification Form

Please fill out our secure insurance verification form below. Please allow up to 1 business day for us to verify the following information and contact you.

What Is Your Full Name (Patient)?(Required)

First Last

What Is Your Phone Number(Required)

This is so we are able to contact you after we have verified your insurance

What Is Your Date Of Birth?(Required)

Are You The Policy Holder?(Required)

Yes, I am the Policy Holder

No I am not the policy holder, it is under someone else's name (Spouse/Parent/Etc)

Please answer yes or no if you are the main policy holder of the policy.

Please Provide The Full Name of The Policy Holder(Required)

First Last

Please Provide The Date Of Birth Of The Policy Holder(Required)

Please Upload A Photo Of The FRONT Of Your Insurance Card(Required)

Accepted file types: jpg, png, pdf, heic, Max. file size: 5 MB.

Please Upload A Photo Of The BACK Of Your Insurance Card(Required)

Accepted file types: jpg, png, pdf, heic, Max. file size: 5 MB.

Please Upload A Photo Of Your State ID or Vehicle License (Patient)

Accepted file types: jpg, png, pdf, heic, Max. file size: 5 MB.

This is optional, please provide it if possible to help expedite the verification process

Please Upload A Photo The Policy Holders State ID or Vehicle License (Policy Holder)

Accepted file types: jpg, png, pdf, heic, Max. file size: 5 MB.

This is optional, please provide it if possible to help expedite the verification process