Brothers Dental and Implants - Dental Insurance Form

Please contact your dental insurance if you need help answering these questions.

Appointment scheduling will only proceed once we receive all the required information.

Marital Status

A dental insurance subscriber is a person who has signed up for dental coverage, typically as an employee or member of a group.

Phone
Name of Dental Insurance*
Dental Plan*

We do not accept any HMO or Medicare/Medicaid Plans

May be your SSN

We are not able to send out any claims to your dental insurance without your SSN.

May be located on the back of your dental card

You can live and work in one state, and have a dental insurance with another state.

SMS Consent*

*Please note that entering responses other than the requested information is not accepted and will result in your appointment not being scheduled.


*Please note that it is the patient's responsibility to provide all information regarding any update to their Dental Insurance. Failure to follow this requirement will result in the patient assuming full responsibility for any outstanding balances.