Dental Hygiene Insurance Breakdown

Patient Name *

Address *

Patient Phone Number *

Insurance Provider 1 *

Insurance 1 Policy Number *

Insurance 1 ID Number *

Deductible per individual ($) *

Deductible per family ($) *

Insurance Provider 2

Insurance 2 Policy Number

Deductible per individual ($)

Deductible per family ($)

Dental Hygiene Coverage/breakdown: Percentage of coverage: Are you eligible for the complete/recall exam? How many units of dental hygiene do you have per year?

Dental Hygiene Coverage/breakdown: Percentage of coverage *

How many units of dental hyiene do you have per year? *

Are you eligible for the complete/recall exam? *YesNo

Are you covered for X-Rays Frequency? *

Are you covered for Fluoride varnish? Frequency? *

Is there an age limit on fluoride varnish applications? *YesNo

If yes, at what age?

Signature *

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Date *