West Georgia Family Dentistry: west georgia family dentistry douglasville ga: On-line Insurance Form

Insurance Information

This is a secure form submitted over SSL.
Click here to access the form in its own window.

Patient's Name

Date

Do you have Dental Insurance ? *

no yes

If so, Please answer the following:

Policy holder's name

Policy holder's date of birth

Policy holder's SS# or ID#

Employer

Employer's phone #

Insurance Company

Mail claims to:

Group or Policy #

Toll free phone #

Please list other family members on policy with their date of birth

Do you have any secondary Dental Insurance ?

no yes

If so, Policy holder's name

Policy holder's date of birth

Policy holder's SS# or ID#

Employer

Employer's phone #

Insurance Company

Mail claims to:

Group or Policy #

Toll free phone #

Payment is required at the time of service for patients to which the insurance company pays directly to them.

Most plans only cover a portion of dental fees. You will be expected to pay any deductibles and co-pay at time of dental service.

By sending this information, you are assigning of benefits for any insurance coverage and as a release of information to your dental insurance company.

Any balance not covered by the insurance company is the responsibility of the patient, and to be paid in full within 30 days.

In the event that the account is turned over to a collection agency, the patient agrees to be responsible for collection fees, attorney fees, court costs, ect.

Any returned checks will be assessed a $25.00 fee.

Broken Appointments or appointments not cancelled withing 48 hours will be assessed a $50.00 fee.

( * Required Field )