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TO OUR PATIENTS

We now have the capability of processing your insurance claims electronically, saving you the time you the time and effort required for mailing. Our office is now connected to a network directly linked to several insurance companies.

If your insurance company is one (1) of those on the network, we will be able to submit your claim or pre-determination directly. This should result in a faster payment from the insurance company. Most insurance companies are part of this program. However, at the time of processing, we will confirm whether your insurance company is an Electronic Data Interchange (EDI) participant.

In order to provide you with maximum benefits from this service, we require the following information:

POLICY HOLDER

Name:

Date of Birth:

Certificate or Employee No:

Name of Insurance Company:

Name of Employer:

Group or Policy No:

Division No:

DEPENDENTS COVERED BY POLICY HOLDER:

Dependent 1:

Date of Birth:

Relationship:

Dependent 2:

Date of Birth:

Relationship:

Dependent 3:

Date of Birth:

Relationship:

Dependent 4:

Date of Birth:

Relationship:

Dependent 5:

Date of Birth:

Relationship:

For dependent children over age of 18, please indicate school:

I authorize my insuring company plan administrator to release the information contained in these claims.

Signature:

Today's Date:

Cornwall Dental Arts

806 Pitt Street
Cornwall, ON K6J 3S2

Monday		8:00am	–	6:00pm
Tuesday		8:00am	–	6:00pm
Wednesday		8:00am	–	5:00pm
Thursday		8:00am	–	5:00pm
Friday		8:00am	–	1:00pm

Professional Affiliates

Cornwall Dental Arts

Hours

Monday		8:00pm	–	6:00pm
Tuesday		8:00pm	–	6:00pm
Wednesday		8:00pm	–	5:00pm
Thursday		8:00pm	–	5:00pm
Friday		8:00pm	–	1:00pm

Location

806 Pitt Street
Cornwall, ON
K6J 3S2

613-932-6923

info@cornwalldentalarts.com

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