Insurance Information Worksheet Name* First Last Address* Street Address City Postal Code Date of Birth* MM slash DD slash YYYY Phone Number*Type of Phone Number* Home Cell Work Email* Preferred Method of Contact* Phone Email When Should We Contact You?*MorningAfternoonEvening Essential Questions to Ask Your Dental Insurance Carrier The following are essential questions that you need to ask your dental insurance carrier in order for us to better provide information as to the financial costs of your dental treatment. By taking a moment to contact your dental carrier and ask these questions, our team will be in a better position to serve you in a timely manner. When contacting your insurance carrier you will require the following:Your insurance company name Your group or plan number Your ID or certificate number What is the maximum benefit that I qualify for each year? Is the Maximum benefit based on a calendar year (Jan-Dec) or per 12 Months? Do I have a major maximum and a basic maximum? Or Is it combined? What percentage of basic dental treatment does my plan cover? (emergency care, root canal, fillings, recalls, sealants, scaling) What percentage of major dental treatment does my plan cover? (crowns, bridges, and replacement of missing teeth with partial dentures, complete dentures and implants etc.)? How often am I covered for a complete or new patient exam? How often am I covered for a recall examination? How many units of scaling and root planning am I covered for? How often am I covered for panoramic xray? How often am I covered for Bitewing xrays? How often am I covered for Polishing? How often am I covered for Fluoride? Are composites (white fillings) covered on molar teeth? How much do I have left for this year on my dental insurance?