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GENERAL DENTISTRY
SAME DAY CROWNS
DENTAL IMPLANTS
COSMETIC DENTISTRY
TEETH WHITENING
SNORING | SLEEP APNEA
INVISIBLE BRACES
VENEERS
PERIODONTAL + GINGIVITIS
TECHNOLOGY
SMILE GALLERY
FORMS + PAY
ADULT PAPERWORK
CHILD PAPERWORK
MAKE A PAYMENT
CIGNA INSURANCE PLAN
CARE CREDIT FINANCING
SUBMIT INSURANCE INFORMATION
RECORDS RELEASE REQUEST
ORAL-B REBATE
About
THE TEAM
DR. LAKEBRINK
DR. MITTS
SMILE GALLERY
OFFICE TOUR
DIRECTIONS + HOURS
FAQ
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ACCESSIBILITY
Make Appointment
HOME
Services
GENERAL DENTISTRY
SAME DAY CROWNS
DENTAL IMPLANTS
COSMETIC DENTISTRY
TEETH WHITENING
SNORING | SLEEP APNEA
INVISIBLE BRACES
VENEERS
PERIODONTAL + GINGIVITIS
TECHNOLOGY
SMILE GALLERY
FORMS + PAY
ADULT PAPERWORK
CHILD PAPERWORK
MAKE A PAYMENT
CIGNA INSURANCE PLAN
CARE CREDIT FINANCING
SUBMIT INSURANCE INFORMATION
RECORDS RELEASE REQUEST
ORAL-B REBATE
About
THE TEAM
DR. LAKEBRINK
DR. MITTS
SMILE GALLERY
OFFICE TOUR
DIRECTIONS + HOURS
FAQ
FOLLOW US!
ACCESSIBILITY
Make Appointment
Insurance Form
INSURANCE VERIFICATION FORM
New Page
Patient Name
First Name
Last Name
Patient Phone Number
POLICY HOLDER / DOB/ SS
POLICY HOLDER EMPLOYER
PATIENTS NAME(S) / DOB(S) / SS#
APPT DATE/ TIME
RECEIVED INS DATE
RECEIVED SHEET
SAM
TRICIA
JORDAN
LAUREN
RALPH
MICHELLE
JULIE
INSURANCE COMPANY
INSURANCE COMPANY PHONE/ ADDRESS
PAYER ID#
DATE CALLED ON
SPOKE WITH
COVERAGE
FAMILY
INDIVIDUAL
EFFECTIVE DATE
RENEWAL DATE
DEDUCTIBLE
ANNUAL MAX
ORTHO MAX
DOES DEDUCTIBLE APPLY TO PREVENTATIVE?
YES
NO
DOES PREVENTATIVE APPLY TOWARDS MAX?
Option One
Option Two
PREVENTATIVE NOTES
PROPHYS/EXAMS
100%
80%
1x6
2x year
2x 12 months
OTHER- SEE NOTES
BITEWINGS
100%
80%
1x6
2x year
2x 12 months
OTHER- SEE NOTES
PANOS
100%
80%
1x12 months
1x36 months (3 years)
1x 60 months (5 years)
OTHER- SEE NOTES
PAs
100%
80%
unlimited
10x year
OTHER- SEE NOTES
FLOURIDE
1x year
2x year
to the age of 13
to the age of 14
to the age of 15
to the age of 16
to the age of 18
OTHER- SEE NOTES
SEALANTS
1x year
2x year
to the age of 13
to the age of 14
to the age of 15
to the age of 16
to the age of 18
OTHER- SEE NOTES
SRP
2 quads in 1 day
all four quads in 1 day
CROWNS
DOWNGRADE
NO DOWNGRADES
CROWN REPLACEMENT
3 years
5 years
7 years
8 years
10 years
FILLINGS
DOWNGRADE
NO DOWNGRADES
MISSING TOOTH CLAUSE
YES
NO
STANDARD COORDINATION OF BENEFITS
YES
NO
INS PAYS ON
PREP
SEAT
WAITING PERIODS
YES
NO
COMP PERIO EVAL
PERIO MAINT
ONLAY
CORE BUILD UP
IMPLANT
CUSTOM ABUTMENT
OCCLUSAL GUARD
EMERGENCY EVAL
2ND OPINION
3/4 CROWN
RECEMENT CROWN
IMPLANT CROWN
PRE-FAB ABUTMENT (METAL)
ORTHODONTICS
Thank you!
