PLD Insurance Form

PROFESSIONAL LANE DENTAL
102 Professional Lane
Dothan, Alabama 36303

Not all of the services we provide are covered by all insurance carriers. We make every effort to inform you if we believe a service may not be covered, however, it is your responsibility to know the coverage limitations of your insurance contract. Since we do contract with many insurance companies, it is impossible for us to know the details of each individual policy. We do not determine the amount of coverage you will receive; your insurance company does this.

You or your employer has purchased your dental insurance. Your plan benefits were negotiated and the contract is between you/employer and the insurance company. Plan benefits are not always made with optimal dental health in mind. It is your responsibility to know your insurance policy, its benefits and requirements. Please be aware that dental insurance does not always cover the entire cost.

While we are happy to assist our patients with filing their insurance, payment is ultimately the responsibility of the patient. We allow your insurance company 60 days to make a payment on your behalf. If after 60 days, we have not received payment, the balance is the responsibility of the patient.

To properly file your insurance, please provide the following information:

Patient Name*

First NameLast Name

Date Of Birth*

Date

Primary Insurance

Insurance Holders Name*

Date Of Birth*

Date

Relationship To Patient*

Insurance Company Name*

Claim Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer*

Employer Phone Number*

Policy Contract Number*

Ins Contract Number

Policy Group Number*

Ins Group Policy

Do You Have A Secondary Insurance?*

NoYes

SECONDARY INSURER

Insurance Holders Name*

First NameLast Name

Date Of Birth Of Policy Holder*

Date

Relationship To Patient*

Insurance Company Name*

Claim Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Employer*

Phone Number*

Policy Contract Number*

Ins Contract Number

Policy Group Number*

Ins Group Number

I authorize the health care provider named above to submit claims for payment for services to an insurance company(s) named above, on my behalf and in my name and assign to such provider the group insurance benefits otherwise payable to me, but not to exceed the provider’s actual charges for the covered services. I understand that I am financially responsible for any charges not covered by the group insurance benefits.

Insured's Signature*