Update Your Insurance Information

This form is for DENTAL INSURANCE ONLY. The information you provide will be used to verify your dental and/or orthodontic benefits, so please fill out this form completely and upload a front & back copy of your primary insurance card and a valid ID. As a courtesy, we will verify your new benefits and file insurance claims on your behalf.

For orthodontics, we will bill any outstanding insurance balance to your new insurance carrier as a courtesy. As disclosed at the beginning of treatment, insurance installments vary, and are generally paid over the course of treatment. If for any reason your insurance carrier does not pay the full estimated benefit, the remaining portion will become the guarantor’s responsibility.

Patient Information

First Name*

Last Name*

Date of Birth*

Street Address*

City*

State*

Zip Code*

Patient is an active patient of the following practice(s): (Check all that apply)*

Naperville Dental SpecialistsInnovative Pediatric DentistryInnovative Orthodontic Centers

Billing Party Information

Billing is different from above (Patients under 18 years old must have a different billing party)

First Name*

Last Name*

Date of Birth*

Address is different from above

Street Address*

City*

State*

Zip Code*

DENTAL Insurance Information

Primary Subscriber Name*

Primary Subscriber DOB*

Employer Name*

Insurance Company*

Group #*

ID #*

Additional family members covered in this policy:

Family Member 1

First Name*

Last Name*

Date of Birth*

Family Member 2

First Name*

Last Name*

Date of Birth*

Family Member 3

First Name*

Last Name*

Date of Birth*

Family Member 4

First Name*

Last Name*

Date of Birth*

Family Member 5

First Name*

Last Name*

Date of Birth*

Upload DENTAL Insurance (Front)*

Upload DENTAL Insurance (Back)*

Upload Drivers License or State ID (Front only)*

Do you have NEW SECONDARY DENTAL INSURANCE?*

YesNo

Secondary Dental Insurance Information

Primary Subscriber Name*

Primary Subscriber DOB*

Employer Name*

Insurance Company*

Group #*

ID #*

Upload SECONDARY Dental Insurance (Front)*

Upload SECONDARY Dental Insurance (Back)*

Contact Info

Contact Email*

Contact Phone*

Additional Notes/Comments

*required fields