Orthodontic Insurance   Our office is happy to assist in submitting your orthodontic insurance claims. However, this is a timely procedure. In order to ensure that your claims are submitted properly, we ask that you assist our staff by obtaining the following information. If you have more than one insurance plan, please include information for both and determine which is the primary coverage.   ALL OF THE QUESTIONS MUST BE ANSWERED FOR THE INSURANCE COMPANY TO ACCEPT YOUR CLAIM. PLEASE USE THIS FORM TO ASSIST YOU. *Patient First Name:   *Patient Birthdate:     *Patient Last Name:       Primary Insurance Secondary Insurance *First Name:   First Name: *Last Name:   Last Name:         *Birthdate:     Birthdate:   *Social Security #/ID #:   Social Security #/ID #:         *Employer:   Employer: *Name of Insurance Carrier:   Name of Insurance Carrier: *Mailing Address of Insurance Carrier:   Mailing Address of Insurance Carrier: *Phone of Insurance Carrier:   Phone of Insurance Carrier: *Group Name and Group Number:   Group Name and Group Number:         Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other   ONCE YOU HAVE THIS INFORMATION, YOU ARE READY TO CALL THE INSURANCE CARRIER AND ASK THE FOLLOWING QUESITONS:   *Do you have the specific coverage for orthodontics? This is SEPARATE from Dental Coverage.   NoYes Do you have the specific coverage for orthodontics? This is SEPARATE from Dental Coverage. NoYes         *Is there a deductible?   Is there a deductible?         *At what age does this coverage expire?   At what age does this coverage expire?         *Has any orthodontic insurance been used, and what is the remaining amount?   Has any orthodontic insurance been used, and what is the remaining amount?         *Is this LIFETIME maximum or a YEARLY amount?   Is this a LIFETIME or YEARLY amount?         *What is the rate of payment? (Usually 50-60%)   What is the rate of payment? (Usually 50-60%)         Thank you for your help! This will help insure that your orthodontic claims are submitted properly and in a timely manner.