Dental Insurance Coordination and Authorization Form

Practices capture a patient's plan details, member ID, and card images before treatment is scheduled. The requested procedure, treating dentist, and estimated cost support pre-authorisation requests. Patients also authorise the clinic to speak with the insurer.

Use this template

Patient's full name

Nombre

Apellido

Date of birth

Email address

Phone number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Insurance provider name

Member ID

Group number

Insurance phone number

Upload insurance card (front and back)

Max 10 MB per file

Requested procedure

Treating dentist

Estimated cost

Is pre-authorization required?

Yes No Not sure

I authorise the clinic to contact my insurer and release the treatment information needed

I authorise contact with my insurer I authorise release of the necessary clinical information

Signature (required)

Sign here

Related templates

Browse all authorization templates →