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Employer
Insurance Information
Do you have Insurance?
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No
Type Of Insurance
Dental
Medical
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Employer
Insurance Company Name
Please Select
AARP Dental Insurance Plan
ACEC Health Plans (Salt Lake City, UT)
Administrative Services (ASO)
Advantage Dental
Aetna
Aetna Affordable Health Choices (SM) - SRC
Aetna DMO
Aetna Medicare
Alameda Alliance
Allcare CCO Dental
Allegiance Benefit Plan Management
Altus Dental
American Medical Security
Ameritas Life Insurance Company
Anthem Health Plans - HMOD & HMOG
Anthem Health Plans of Virgina - OSB HIGH & LOW
Anthem Health Plans of Virgina - PPOB & PPOD
Anthem Health Plans of Kentucky - OSB HIGH & LOW
Anthem Health Plans of Kentucky - PPOB & PPOD
Anthem HMO Colorado - HMO-B
Anthem Insurance - OSB HIGH & LOW
Anthem Insurenace - PPOB & PPOD
APIPA (Arizona Physicians IPA) - Claims ONLY
APIPA (Arizona Physicians IPA) - PreDeterminations
Asuris Northwest Health
Aultcare
Aultra Administrative Group
AVESIS
Bell Atlantic
Benefit Inc
Benefits Inc
Blue Advantage (BCBS of AR)
Blue Cross Blue Shield (Anthem)
Blue Cross Blue Shield (Empire)
Blue Cross Blue Shield (Trigon)
Blue Cross Blue Shield of Alabama
Blue Cross Blue Shield of Alaska (Premera)
Blue Cross Blue Shield of Arizona
Blue Cross Blue Shield of Arkansas
Blue Cross Blue Shield of Colorado
Blue Cross Blue Shield of Connecticut
Blue Cross Blue Shield of CT- Family Plan
Blue Cross Blue Shield of Delaware
Blue Cross Blue Shield of Georgia
Blue Cross Blue Shield of Illinois
Blue Cross Blue Shield of Indiana (Anthem)
Blue Cross Blue Shield of Indiana (FEP)
Blue Cross Blue Shield of Kansas
Blue Cross Blue Shield of Kansas City
Blue Cross Blue Shield of Kentucky (FEP)
Blue Cross Blue Shield of Kentucky (Anthem)
Blue Cross Blue Shield of Maine
Blue Cross Blue Shield of Maryland / CAREFIRST
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of MI/ Medicare Advantage
Blue Cross Blue Shield of Michigan
Blue Cross Blue Shield of Minnesota (FEP)
Blue Cross Blue Shield of Minnesota
Blue Cross Blue Shield of Mississippi (CHIPs)
Blue Cross Blue Shield of Missouri
Blue Cross Blue Shield of Montana
Blue Cross Blue Shield of Nevada
Blue Cross Blue Shield of New Hampshire
Blue Cross Blue Shield of New Jersey (Horizon)
Blue Cross Blue Shield of New Mexico
Blue Cross Blue Shield of Ohio (Anthem)
Blue Cross Blue Shield of Ohio (FEP)
Blue Cross Blue Shield of Oklahoma
Blue Cross Blue Shield of Oregon (Regence)
Blue Cross Blue Shield of Rhode Island
Blue Cross Blue Shield of Tennessee
Blue Cross Blue Shield of Texas
Blue Cross Blue Shield of Virginia (Trigon)
Blue Cross Blue Shield of Washington (Regence)
Blue Cross Blue Shield of Washington DC
Blue Cross Blue Shield of Washington
Blue Cross Blue Shield of Western New York
Blue Cross Blue Shield of Wisconsin - PPOD
Blue Cross Blue Shield of Wisconsin
Blue Cross Blue Shield of Wyoming
Blue Cross ND (North Dakota Dental Service)
Blue Cross of California - OSB HIGH & LOW
Blue Cross of California - PLAN SS10 & SS20
Blue Cross of California - PPOA
Blue Cross of California (Wellpoint)
Blue Shield of California
Blue Shield of California - Federal
Blue Shield of Idaho (Regence)
Blue Shield of Northeast New York
Blue Shield of Pennsylvania
Blue Shield of Pennsylvania - Dental Plus
Boston University Dental Health Plan
Brokers National
Businessmen's Assurance (NE)
CAL Optimal - ONECARE
Capitol Dental
Care1st Health Plan Medicare Advantage
Care1st PHP LA & San Bernadino County
Caresource - GA
Caresource - West Virginia
Carpenters Combined Funds
Carpenters Health and Welfare Trust Funds
Caterpillar Inc
Central PA Teamsters Health & Welfare Fund
Chicago Regional Council of Carpenters
Choice Plus (TRW)
Cigna
Cigna (DHMO)
Cigna Dental (HMO)
Community Insurance - PPOD & PPOF
Community Insurance - HMOA & PPOB
CompBenefits
COMPREHENSIVE CARE SERVICE (CCSTPA)
Connecticut Carpenters Health Fund
Connecticut Carpenters Health Plan
Connecticut General (Cigna)
Cooperative Benefit Administrators
CustomCare (Southwest Bell Execs)
Delta Dental - DDIC
Delta Dental Individual Plan (WA,VA,WI,NJ)
Delta Dental of Alabama
Delta Dental of Alaska
Delta Dental of Arizona
Delta Dental of Arkansas Ind
Delta Dental of Arkansas
Delta Dental of California
Delta Dental of Colorado
Delta Dental of Connecticut
Delta Dental of Delaware
Delta Dental of District of Columbia (DC)
Delta Dental of Florida
Delta Dental of Georgia
Delta Dental of Idaho
Delta Dental of Illinois (Group Plans)
Delta Dental of Illinois (Individual)
Delta Dental of Indiana
Delta Dental of Iowa - DWP
Delta Dental of Iowa
Delta Dental of Kansas
Delta Dental of Kentucky
Delta Dental of Louisiana
Delta Dental of Maine
Delta Dental of Maryland
Delta Dental of Massachusetts
Delta Dental of Michigan
Delta Dental of Minnesota
Delta Dental of Mississippi
Delta Dental of Missouri
Delta Dental of Montana
Delta Dental of Nebraska
Delta Dental of Nevada
Delta Dental of New Hampshire
Delta Dental of New Jersey
Delta Dental of New Mexico
Delta Dental of New York
Delta Dental of North Carolina
Delta Dental of North Dakota
Delta Dental of Northeast (ME NH VT)
Delta Dental of Ohio
Delta Dental of Oklahoma
Delta Dental of Oregon
Delta Dental of Pennsylvania
Delta Dental of Puerto Rico
Delta Dental of Rhode Island
Delta Dental of South Carolina
Delta Dental of Tennessee
Delta Dental of Texas
Delta Dental of Utah
Delta Dental of Vermont
Delta Dental of Virginia
Delta Dental of Washington
Delta Dental of West Virginia
Delta Dental of Wisconsin
DeltaCare USA / PMI - Claims
DeltaCare USA / PMI - Encounters
Dental Benefit Providers
Dental3
Dentaquest - Commercial
DentaQuest (Government)
Deseret Mutual Benefit Administrators
Eastern Life and Health
EasyChoice Health Plan
EHI
Emphesys Employers Health of Wisconsin
Empire Health Choice - HMO
Empire Health Choice Assurance - OSB LOW & PPOB
Employers Health Ins of Winconsin(EHI) (Emphesys)
Encara
Envolve Dental
Equicor
Equitable
FedEx Freight East
FedEx Freight Health Benefit
First Ameritas Life Insurance Corp of New York
First Commonwealth
First Plan Blue
First Reliance Standard Life - New York
FLEX Compensation
FlexCare
Florida Combined Life (BCBS of FL)
Florida Power and Light
Gateway Healthy Plan
GEGLAC - GE Group Life Assurance Company - Dental
GEHA Employee Program
Genworth Life and Health Insurance Company
GIC (Indemnity Plan
Golden State Health Plan
Golden West Dental
Great West Healthcare
Great-West Healthcare
Guardian Life Insurance Co
Guardian Managed DentalGuard (Individual Market)
Happy Vyneyard Smiles
Hawaii Dental Services (Delta Dental of HI)
Health Benefit Claims Dept
Health Net - Healthy Families A, B & C
Health Net - Los Angeles PHP
Health Net - Sacramento GMC
Health Net 21 - LA & Sacramento
Healthnet of Oregon
Healthy Alliance Life Insurance - PPOB
HMSA (Hawaii Medical Services) - Commercial
Horizon Healthcare OF New York
Humana Dental
IBEW Local 38
Independence Blue Cross Dental Plan - BlueExtraSM
LA Care Health Plan
Liberty Dental Plan
Lifemap Dental Claims
LifeRe
Lincoln National (WI)
MANAGED CARE OF NORTH AMERICA (MCNA)
Marriott
MD Care Health Plan
MEDICA of Minnesota
MEDICA Public Programs
Medicaid of Alabama
Medicaid of Colorado
Medicaid of Connecticut
Medicaid of Hawaii (Hawaii Dental Services)
Medicaid of Idaho
Medicaid of Illinois
Medicaid of Indiana
Medicaid of Kentucky(Region 3 - Doral Dental)
Medicaid of Maryland
Medicaid of Massachusetts (Mass Health)
Medicaid of Mississippi
Medicaid of North Carolina
Medicaid of Ohio
Medicaid of South Carolina
Medicaid of Utah
Medicaid of Virgina
Medicaid of Washington
Medical Mutual of Ohio (MMO)
Mercy Care
Meritain Health
MetLife
METRO Health Plan
MGM Resorts International
Michigan Laborers Health Care Fund
Midwest Operating Engineers Health and Welfare
Molina Healthcare
Molina Healthcare (Administered By Liberty)
Mutual Health Services
Mutual of Omaha
MVP - Select Care
National Automatic Sprinkler Industry
National Pacific of Texas (NCFLEX)
New England Financial
North Carolina Health Choice
North Star Administrators
Northern California Pipe Trades Trust
Northwest Dental Services
Ohana Health Plan
Ozark Health Plan
Pacific Dental Benefits - California
Pacific Dental Benefits - Nevada
Pacific Union (CA)
Pacificare Dental & Vision Plan
Palms Casino Resport
PDO (Preferred Dental Organization)
Personal Choice
Physicians Mutual
Physicians United PLAN - PUP
Pipefitters LOCAL 597 Welfare Fund
Premera Blue Cross
PrimeWest Health
Principal Financial Group
Principal Life Insurance Co
Provident Life & Accident Insurance Co of America
Prudential for Health
Prudential HealthCare and Life Ins Co of America
Prudential HealthCare Health Maintenance Org
Prudential HealthCare HMO for Small Business
Prudential HealthCare of America Inc
Prudential HealthCare POS for Small Business
Prudential HealthCare PPO for Small Business
Reliance Standard Life
Reliastar (CA)
Rocky Mntn Hospital & Medical Srvc-OSB HIGH & HIGH
Sands Bethworks Gaming
Santa Clara Family Health Plan
SCION Dental
SCION Dental Commercial
Security Life Insurance Company of America
Select Health
South Carolina Healthy Connections
Southwestern Bell
Southwestern Bell Exec - Custom Care
Southwestern Bell Exec - Southwestern Bell
Standard Insurance Company of New York
Standard Insurance Company of Oregon
Sun Life & Health Ins Co
Sun Life Financial
The Dental Companies
The Dental Concern
The Dental Network of Maryland
Travelers (now MetLife )
Tricare Dental Plan (UCCI)
Tricare Retiree Dental
UFCW of Central Ohio
UHC - BCBS NC
UHC Dental Government Programs
UHC Medicare
UMR
UMR - Harrington
UMR - San Antonio
UNICARE
United Concordia - Dental Plus
United Concordia - Fee for Service
United Healthcare Dental
United Medical Resources - Cincinnati
Varian Health Care Plan
Venetian
Vyne Dental Plans
Wellborn Health Plans
Wellcare
Wellpoint
Western PA Teamsters Fund
Wilson McShane Corporation
WV PEIA
Zenith Administrators (MN)
Other
I.D. #
If Other
Address
City
State
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Group #
Group Name
Policy Holder First Name
Policy Holder Last Name
Relation
Insured Birthdate
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
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2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
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1907
1906
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1904
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1902
1901
1900
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1896
1895
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1890
1889
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1887
1886
1885
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1836
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1834
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1830
1829
1828
1827
1826
1825
Social Sec. #
Phone
Address
City
State
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Do You Have Secondary Insurance?
Yes
No
Secondary Type
Dental
Medical
Take or Add a Photo of Both Sides of Your Insurance Card
Upload
or drag files here
Employer For Secondary
Secondary Ins. Company Name
Please Select
AARP Dental Insurance Plan
ACEC Health Plans (Salt Lake City, UT)
Administrative Services (ASO)
Advantage Dental
Aetna
Aetna Affordable Health Choices (SM) - SRC
Aetna DMO
Aetna Medicare
Alameda Alliance
Allcare CCO Dental
Allegiance Benefit Plan Management
Altus Dental
American Medical Security
Ameritas Life Insurance Company
Anthem Health Plans - HMOD & HMOG
Anthem Health Plans of Virgina - OSB HIGH & LOW
Anthem Health Plans of Virgina - PPOB & PPOD
Anthem Health Plans of Kentucky - OSB HIGH & LOW
Anthem Health Plans of Kentucky - PPOB & PPOD
Anthem HMO Colorado - HMO-B
Anthem Insurance - OSB HIGH & LOW
Anthem Insurenace - PPOB & PPOD
APIPA (Arizona Physicians IPA) - Claims ONLY
APIPA (Arizona Physicians IPA) - PreDeterminations
Asuris Northwest Health
Aultcare
Aultra Administrative Group
AVESIS
Bell Atlantic
Benefit Inc
Benefits Inc
Blue Advantage (BCBS of AR)
Blue Cross Blue Shield (Anthem)
Blue Cross Blue Shield (Empire)
Blue Cross Blue Shield (Trigon)
Blue Cross Blue Shield of Alabama
Blue Cross Blue Shield of Alaska (Premera)
Blue Cross Blue Shield of Arizona
Blue Cross Blue Shield of Arkansas
Blue Cross Blue Shield of Colorado
Blue Cross Blue Shield of Connecticut
Blue Cross Blue Shield of CT- Family Plan
Blue Cross Blue Shield of Delaware
Blue Cross Blue Shield of Georgia
Blue Cross Blue Shield of Illinois
Blue Cross Blue Shield of Indiana (Anthem)
Blue Cross Blue Shield of Indiana (FEP)
Blue Cross Blue Shield of Kansas
Blue Cross Blue Shield of Kansas City
Blue Cross Blue Shield of Kentucky (FEP)
Blue Cross Blue Shield of Kentucky (Anthem)
Blue Cross Blue Shield of Maine
Blue Cross Blue Shield of Maryland / CAREFIRST
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of MI/ Medicare Advantage
Blue Cross Blue Shield of Michigan
Blue Cross Blue Shield of Minnesota (FEP)
Blue Cross Blue Shield of Minnesota
Blue Cross Blue Shield of Mississippi (CHIPs)
Blue Cross Blue Shield of Missouri
Blue Cross Blue Shield of Montana
Blue Cross Blue Shield of Nevada
Blue Cross Blue Shield of New Hampshire
Blue Cross Blue Shield of New Jersey (Horizon)
Blue Cross Blue Shield of New Mexico
Blue Cross Blue Shield of Ohio (Anthem)
Blue Cross Blue Shield of Ohio (FEP)
Blue Cross Blue Shield of Oklahoma
Blue Cross Blue Shield of Oregon (Regence)
Blue Cross Blue Shield of Rhode Island
Blue Cross Blue Shield of Tennessee
Blue Cross Blue Shield of Texas
Blue Cross Blue Shield of Virginia (Trigon)
Blue Cross Blue Shield of Washington (Regence)
Blue Cross Blue Shield of Washington DC
Blue Cross Blue Shield of Washington
Blue Cross Blue Shield of Western New York
Blue Cross Blue Shield of Wisconsin - PPOD
Blue Cross Blue Shield of Wisconsin
Blue Cross Blue Shield of Wyoming
Blue Cross ND (North Dakota Dental Service)
Blue Cross of California - OSB HIGH & LOW
Blue Cross of California - PLAN SS10 & SS20
Blue Cross of California - PPOA
Blue Cross of California (Wellpoint)
Blue Shield of California
Blue Shield of California - Federal
Blue Shield of Idaho (Regence)
Blue Shield of Northeast New York
Blue Shield of Pennsylvania
Blue Shield of Pennsylvania - Dental Plus
Boston University Dental Health Plan
Brokers National
Businessmen's Assurance (NE)
CAL Optimal - ONECARE
Capitol Dental
Care1st Health Plan Medicare Advantage
Care1st PHP LA & San Bernadino County
Caresource - GA
Caresource - West Virginia
Carpenters Combined Funds
Carpenters Health and Welfare Trust Funds
Caterpillar Inc
Central PA Teamsters Health & Welfare Fund
Chicago Regional Council of Carpenters
Choice Plus (TRW)
Cigna
Cigna (DHMO)
Cigna Dental (HMO)
Community Insurance - PPOD & PPOF
Community Insurance - HMOA & PPOB
CompBenefits
COMPREHENSIVE CARE SERVICE (CCSTPA)
Connecticut Carpenters Health Fund
Connecticut Carpenters Health Plan
Connecticut General (Cigna)
Cooperative Benefit Administrators
CustomCare (Southwest Bell Execs)
Delta Dental - DDIC
Delta Dental Individual Plan (WA,VA,WI,NJ)
Delta Dental of Alabama
Delta Dental of Alaska
Delta Dental of Arizona
Delta Dental of Arkansas Ind
Delta Dental of Arkansas
Delta Dental of California
Delta Dental of Colorado
Delta Dental of Connecticut
Delta Dental of Delaware
Delta Dental of District of Columbia (DC)
Delta Dental of Florida
Delta Dental of Georgia
Delta Dental of Idaho
Delta Dental of Illinois (Group Plans)
Delta Dental of Illinois (Individual)
Delta Dental of Indiana
Delta Dental of Iowa - DWP
Delta Dental of Iowa
Delta Dental of Kansas
Delta Dental of Kentucky
Delta Dental of Louisiana
Delta Dental of Maine
Delta Dental of Maryland
Delta Dental of Massachusetts
Delta Dental of Michigan
Delta Dental of Minnesota
Delta Dental of Mississippi
Delta Dental of Missouri
Delta Dental of Montana
Delta Dental of Nebraska
Delta Dental of Nevada
Delta Dental of New Hampshire
Delta Dental of New Jersey
Delta Dental of New Mexico
Delta Dental of New York
Delta Dental of North Carolina
Delta Dental of North Dakota
Delta Dental of Northeast (ME NH VT)
Delta Dental of Ohio
Delta Dental of Oklahoma
Delta Dental of Oregon
Delta Dental of Pennsylvania
Delta Dental of Puerto Rico
Delta Dental of Rhode Island
Delta Dental of South Carolina
Delta Dental of Tennessee
Delta Dental of Texas
Delta Dental of Utah
Delta Dental of Vermont
Delta Dental of Virginia
Delta Dental of Washington
Delta Dental of West Virginia
Delta Dental of Wisconsin
DeltaCare USA / PMI - Claims
DeltaCare USA / PMI - Encounters
Dental Benefit Providers
Dental3
Dentaquest - Commercial
DentaQuest (Government)
Deseret Mutual Benefit Administrators
Eastern Life and Health
EasyChoice Health Plan
EHI
Emphesys Employers Health of Wisconsin
Empire Health Choice - HMO
Empire Health Choice Assurance - OSB LOW & PPOB
Employers Health Ins of Winconsin(EHI) (Emphesys)
Encara
Envolve Dental
Equicor
Equitable
FedEx Freight East
FedEx Freight Health Benefit
First Ameritas Life Insurance Corp of New York
First Commonwealth
First Plan Blue
First Reliance Standard Life - New York
FLEX Compensation
FlexCare
Florida Combined Life (BCBS of FL)
Florida Power and Light
Gateway Healthy Plan
GEGLAC - GE Group Life Assurance Company - Dental
GEHA Employee Program
Genworth Life and Health Insurance Company
GIC (Indemnity Plan
Golden State Health Plan
Golden West Dental
Great West Healthcare
Great-West Healthcare
Guardian Life Insurance Co
Guardian Managed DentalGuard (Individual Market)
Happy Vyneyard Smiles
Hawaii Dental Services (Delta Dental of HI)
Health Benefit Claims Dept
Health Net - Healthy Families A, B & C
Health Net - Los Angeles PHP
Health Net - Sacramento GMC
Health Net 21 - LA & Sacramento
Healthnet of Oregon
Healthy Alliance Life Insurance - PPOB
HMSA (Hawaii Medical Services) - Commercial
Horizon Healthcare OF New York
Humana Dental
IBEW Local 38
Independence Blue Cross Dental Plan - BlueExtraSM
LA Care Health Plan
Liberty Dental Plan
Lifemap Dental Claims
LifeRe
Lincoln National (WI)
MANAGED CARE OF NORTH AMERICA (MCNA)
Marriott
MD Care Health Plan
MEDICA of Minnesota
MEDICA Public Programs
Medicaid of Alabama
Medicaid of Colorado
Medicaid of Connecticut
Medicaid of Hawaii (Hawaii Dental Services)
Medicaid of Idaho
Medicaid of Illinois
Medicaid of Indiana
Medicaid of Kentucky(Region 3 - Doral Dental)
Medicaid of Maryland
Medicaid of Massachusetts (Mass Health)
Medicaid of Mississippi
Medicaid of North Carolina
Medicaid of Ohio
Medicaid of South Carolina
Medicaid of Utah
Medicaid of Virgina
Medicaid of Washington
Medical Mutual of Ohio (MMO)
Mercy Care
Meritain Health
MetLife
METRO Health Plan
MGM Resorts International
Michigan Laborers Health Care Fund
Midwest Operating Engineers Health and Welfare
Molina Healthcare
Molina Healthcare (Administered By Liberty)
Mutual Health Services
Mutual of Omaha
MVP - Select Care
National Automatic Sprinkler Industry
National Pacific of Texas (NCFLEX)
New England Financial
North Carolina Health Choice
North Star Administrators
Northern California Pipe Trades Trust
Northwest Dental Services
Ohana Health Plan
Ozark Health Plan
Pacific Dental Benefits - California
Pacific Dental Benefits - Nevada
Pacific Union (CA)
Pacificare Dental & Vision Plan
Palms Casino Resport
PDO (Preferred Dental Organization)
Personal Choice
Physicians Mutual
Physicians United PLAN - PUP
Pipefitters LOCAL 597 Welfare Fund
Premera Blue Cross
PrimeWest Health
Principal Financial Group
Principal Life Insurance Co
Provident Life & Accident Insurance Co of America
Prudential for Health
Prudential HealthCare and Life Ins Co of America
Prudential HealthCare Health Maintenance Org
Prudential HealthCare HMO for Small Business
Prudential HealthCare of America Inc
Prudential HealthCare POS for Small Business
Prudential HealthCare PPO for Small Business
Reliance Standard Life
Reliastar (CA)
Rocky Mntn Hospital & Medical Srvc-OSB HIGH & HIGH
Sands Bethworks Gaming
Santa Clara Family Health Plan
SCION Dental
SCION Dental Commercial
Security Life Insurance Company of America
Select Health
South Carolina Healthy Connections
Southwestern Bell
Southwestern Bell Exec - Custom Care
Southwestern Bell Exec - Southwestern Bell
Standard Insurance Company of New York
Standard Insurance Company of Oregon
Sun Life & Health Ins Co
Sun Life Financial
The Dental Companies
The Dental Concern
The Dental Network of Maryland
Travelers (now MetLife )
Tricare Dental Plan (UCCI)
Tricare Retiree Dental
UFCW of Central Ohio
UHC - BCBS NC
UHC Dental Government Programs
UHC Medicare
UMR
UMR - Harrington
UMR - San Antonio
UNICARE
United Concordia - Dental Plus
United Concordia - Fee for Service
United Healthcare Dental
United Medical Resources - Cincinnati
Varian Health Care Plan
Venetian
Vyne Dental Plans
Wellborn Health Plans
Wellcare
Wellpoint
Western PA Teamsters Fund
Wilson McShane Corporation
WV PEIA
Zenith Administrators (MN)
Other
Secondary Ins. I.D. #
If Other
Address
City
State
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Secondary Ins. Group #
Secondary Ins. Group Name
Policy Holder First Name
Policy Holder Last Name
Relation To Patient
Secondary Insured Birthdate
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Secondary Insured Social
Phone
Address
City
State
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to this dental office all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.
Signature
Sign Here
×
Signature Pad
Date
Jan
Feb
Mar
Apr
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Dec
1
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