Insurance Verification Form

Please complete the Insurance Verification Request Form.

Please complete all fields to the right so that our Insurance Coordinator can accurately verify your benefits for you. Please ensure all fields are accurate & complete - incorrect or incomplete insurance information may result in denial or reduction of your dental claim(s).

Remember to update this form for any future changes in employment or any insurance coverages changes - as this will change the estimated insurance benefits which are paid out over the course of your orthodontic treatment.

For existing patients: Work-in-progress claim requests cannot be completed if all fields are not correctly completed as your insurance will not process the claim without all the requested information.

If you have any questions related to your insurance please email us at info@tri-ortho.com.

Please select the item which best applies to you:

I'm a new patient requesting insurance verification

I'm a new patient providing secondary insurance information

I'm an existing patient coming in for a recall/second consultation and would like my new insurance policy verified.

I'm an existing patient and this is for a work-in-progress claim request (primary insurance has terminated)

I'm an existing patient and this is for a work-in-progress claim request (primary insurance is still active)

Patient Name

First Name

Last Name

Patient Date of Birth

YYYY

Policy Holder Name

First Name

Last Name

Policy Holder Date of Birth

YYYY

Employer Name

Insurance Company Name (for ex. Delta of CA - for Delta pls specify which state, or Metlife, Cigna etc)

Will your insurance policy by changing or terminating soon?

If so please explain below (provide termination date if applicable) and contact our Insurance Coordinator at Frontdesk@tri-ortho.com, as this will change your expected benefits.

Subscriber ID Number

Group Number

Your Email

Effective Date of policy provided (Required for Work-in-Progress requests only)

For work-in-progress claim requests the effective date of your new policy must be provided in order for our team to prepare your claim for you.

YYYY

Termination Date of your previous policy (Required for Work-in-Progress requests only)

For work-in-progress claim requests the termination date of your previous policy must be provided for our team to prepare a work-in-progress claim for you

YYYY

Please email a copy of the front & back of your insurance card to info@tri-ortho.com

Your submission will be complete after we receive this email - Thank you.

Insurance Verification Form

Please complete the Insurance Verification Request Form.

Location

Links

Hours

Contact