Patient Information
Patient Forms
If you are interested in becoming a new patient, or if your information has changed, please complete the Patient Forms Packet below. The link will bring you to a new page for digital submission. These forms detail patient information, your medical history, your consent to our financial policy, and your understanding of and consent to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Patient Privacy Notice
Click below to download a copy of our Notice of Privacy Practices for your records. You do not need to fill out or return this form, but it is important that you read and understand it.
Dental Insurance
Our office is happy to work with you and your dental insurance. We will submit insurance claims for most plans, whether we participate or not, as a courtesy to our patients. Most insurances now accept electronic claims, which are submitted at the time of treatment. Those that do not receive claims electronically are submitted within 2 days of treatment.
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When your treatment is extensive or costly, we can submit a pre-treatment estimate to the insurance company, requesting detailed information on each item of dental treatment needed and your exact financial responsibility.
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The list of insurances we participate with are as follows:
CSEA
ProBenefits
Tricare United Concordia Military
Univera (Select Plans)
We will submit insurance claims on the patient's behalf for most other insurance companies. If you do not see your insurance carrier on the list, feel free to give us a call.
If your insurance has changed, please call our office with your new insurance company, address, phone number, group number, and subscriber ID number.