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INSURANCE INFORMATION FORM

Please take a few moments to complete the insurance information form below in order to help you estimate the amount of reimbursement you may receive from your insurance company for Invisalign Orthodontic treatment. 
Please ensure that you complete all the sections and sign the authorization at the bottom.

Treatment for

PRIMARY INSURANCE INFORMATION

Relationship to policy holder

OPTIONAL: Please upload photo(s) of your insurance card or a screenshot

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AUTHORIZED CONSENT TO RELEASE INFORMATION

Consent Required

If you currently have dental insurance, your insurance company has a policy with you to provide the necessary payments for dental services rendered according to a previously agreed upon contract with yourself directly or through your employer. It has been our experience that these dental insurance contracts vary greatly between companies. Therefore, because of these variations, Peak Smiles and staff cannot be responsible for knowing all of the options and limitations of your particular plan. It is the responsibility of you, the customer, to be completely aware of the specifics of your own benefits.

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