Dental Insurance Claim Form
Patient Information
Full Name
Date of Birth
Gender
Female
Male
Other
Address
Phone
Email
Insurance Information
Insurance Company
Policy Number
Group Number
Insured’s Name
Relationship to Patient
Dental Treatment Details
Date of Service
Procedure Code(s)
Tooth Number(s)
Description of Services
Amount Claimed
Dentist Information
Dentist Name
License Number
Phone
Signature
Patient/Guardian Signature
Date