Form: Dental Insurance – Long Beach Dentist Office | Call (562) 421-3747 | Holistic Dentistry CA

Insurance benefits vary considerably from contract to contract. In spite of our efforts, we find it impossible to be sure what you will get back ... it's very frustrating.

Although we are not contracted with any dental insurance companies, for those of you that have dental insurance that allows freedom of choice of dentists, we fully commit to obtaining any and all benefits that lie within your contract. If you would be interested in learning why we are not contracted with 3rd parties, go to our website, www.LongBeachHolisticDentist.com, click the "Resources" tab, go to articles, and scroll down to the "Dental Insurance Misnomer" article.

The financial obligation for dental treatment is between you and our office - your insurance company is responsible to you, and not to our office. We will assist you in any way that we can.

To expedite your receiving all benefits due you, please fill out the following:

Your Name (required)	Your Email (required)
Name of Insured :	Birth date:
Social Security Number:	Employer Name:
Insurance company (Carrier) name:	Name of Group Plan:
Group number:	Address of insurance company:
City:	State:
Zip Code:	Phone number of insurance company:

If you have secondary dental insurance:

Name of other insured party:	Social Security Number:
Date of Birth of other insured party:	Employer Name:
Insurance company (Carrier) name:	Name of Group Plan:
Group number:	Address of insurance company:
City:	State:
Zip Code:	Phone number of insurance company:

After you hit the "Send" button to submit this form, you will see a confirmation below that the form has been sent. Then click the "Next" button to continue to the next form.

FIRST STEP: THEN CLICK NEXT TO CONTINUE:

Mon-Tues-Wed	8:00 am – 5:00 pm
Thurs	7:00 am – 4:00 pm
Friday	Closed
Sat & Sun	Closed