Dental Insurance E-Form

Dental Insurance E-Form

Please take your time and fill out as much of this form as possible.Due to HIPPA privacy laws, some sections cannot be filled out online and can only be completed in the office. If you have questions we'll be glad to help. We look forward to working with you.
Primary Dental Insurance
Please enter the primary dental insurance information and insured person’s information below:
Primary Dental Insurance Company Name:
Dental Insurance Phone Number:
Group Name or Employer Name:
Group Number:
Subscriber Name:

First Name Middle Name Last Name
Subscriber Date of Birth:

/ Month / Day Year
Subscriber Member ID or SS#:
Relationship to Patient:
Patient Name:

First Name Last Name
Patient Date of Birth:

/ Month / Day Year
Secondary Dental Insurance
Please enter the secondary dental insurance information and insured person’s information below:
Secondary Dental Insurance Company Name:
Dental Insurance Phone Number:
Group Name or Employer Name:
Group Number:
Subscriber Name:

First Name Middle Name Last Name
Subscriber Date of Birth:

/ Month / Day Year
Subscriber Member ID or SS#:
Relationship to Patient:
Patient Name:

First Name Last Name
Patient Date of Birth:

/ Month / Day Year
This form MUST be signed in the office

Authorization

I certify that I, and/or my dependent(s), have insurance coverage with (Name of Insurance Company(ies)) ________________________________________ and assign directly to Dr. Kevin Landers all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

__________________________________

Patient/Guardian Signature

_____/_______/________

Date

__________________________________

Please print name of Patient/Guardian

_________________________________

Relationship to Patient

Payment is due in full at time of treatment unless prior arrangements have been approved.
Summary
Check Off Items Below To Indicate The E-Forms You Filled Out On Our Website:

Patient Personal Information Form (Faxed to: 312 263-7013) Medical Health History E-Form Dental Health History E-Form Cosmetic Questionnaire E-Form Cyber Consult *Send X-Rays & Images Personal Preferences Patient Communication E-Form Pain Management Patient Communication E-Form Bad Dental Experience Patient Communication E-Form Patient Satisfaction Survey E-Form
We appreciate your time expressing your past experiences and personal preferences. Your efforts will afford our team to ability to focus on your specific preferences and ultimately provide you with the best dental experience.

If you are a New Patient

You can fill out your new patient paper work now

1. Patient Personal Information Form (Print, Fill Out & Fax or Email)

2. Medical Health History E-Form

3. Dental History E-form

If you have had a Bad Dental Experience, we strongly recommend you review

Bad Dental Experience Patient communication E-form

Recommended Reading:

1. Relaxation Techniques To Stay Calm During Dental Treatments

2. Self Help Strategies to overcome Dental Pain & Fear

3. Top 25 Dental Fears & Our Solutions “Facing Your Fears”

For Those Seeking Exceptional Care, please fill out:

Personal Preferences Patient Communication E-Form

For Those Seeking Cosmetic treatment, its “Very important” that you fill out:

Cosmetic Questionnaire

.

What Happens Next

It’s required that we keep your online information private and secure. Accordingly you will need to create and enter a 4-6 digit ID number on any E-form filled out on our site. Retain this 4-6-digit number as you will need to provide it to our scheduling coordinator. In turn, they will download your online information and save it to a new account hosted on our private secure server.

Your best option is to call our office in advance of your appointment date. This will allow extra time for Dr Landers to review the E-forms you took your time to fill out.

When you Call Please provide the Following E-form Information:

1. First & Last Name

2. The Names of E-Forms You Fill Out Online

3. The 4-6 Digit Number You Entered On The E-Forms.

We Will Use This ID Number To Attach Your E-Forms “Privately” To Your New Account At Our Office

Contact Us Today! 312-263-7823
To keep your information private and secure, please enter a 4-6 digit ID number of your choice below. Retain this 4-6 digit ID number as you will need to provide our office staff with that number during your appointment so we may retrieve your submission. You may also call our office beforehand and provide us with that number. *
Copyright Statement

Advanced Cosmetic & Implant Dentistry, has exclusive rights under U.S. and foreign copyright laws. Unless otherwise indicated, all materials on these pages are copyrighted by the Advanced Cosmetic & Implant Dentistry inc. All rights reserved. No part of these pages, either text or image may be used for any purpose other than personal use. Therefore, reproduction, modification, storage in a retrieval system or retransmission, in any form or by any means, electronic, mechanical, or otherwise, for reasons other than personal use, is strictly prohibited without prior written permission.

© Advanced Cosmetic & Implant Dentistry
ChicagosCosmeticDentist.com
312-263-7823
Should be Empty:

Primary Dental Insurance

Secondary Dental Insurance

Summary