Dental Benefits Plan Information 

​To help us submit claims and provide accurate estimates, please provide the following details about your dental plan:

Basic Plan Information

• Insurance company name: __________________________
• Policy / Contract number: __________________________
• Certificate / ID number: __________________________

Coverage Details

• Annual maximum: $________________
• Annual deductible: $________________
• Fee guide used (e.g., ODA 2024): __________________________
• Benefit year:
  • ☐ Calendar year (Jan–Dec)
  • ☐ Rolling 12‑month cycle: __________________

Types of Coverage

• Crown & bridge coverage: ☐ Yes ☐ No
• Denture coverage: ☐ Yes ☐ No
  • If yes, replacement frequency: __________________________​​​​
  • Orthodontic coverage: ☐ Yes ☐ No
    • Lifetime maximum: $________________

​​ Percentages Covered

• Basic services: ________%
• Major services: ________%

​Recall & Hygiene Limits

• Recall frequency (exams/cleanings):
  • ☐ Every 6 months
  • ☐ Every 9 months
  • ☐ Every 12 months
  • ☐ Other: __________________
• Units of scaling covered per year: ________ units

Secondary Insurance (If Applicable)

• Secondary insurer name: __________________________
• Policy / Contract number: __________________________
• Certificate / ID number: _________________________