Shoreline Dental Care LLC

Dental Insurance Information Form

Welcome to Shoreline Dental Care LLC. We apprectate your confidence in our dental health team and pledge to provide you with the highest level of professional care possible. In order to help us ensure your health and comfort, we ask that you complete SHORELINE the following form. All formation will be held in the strictest confidence. If you have any questions or require help, please ask DENTAL CARE and we will be happy to assist you.


Patient Name
Subscriber Name
Subscriber Address*
Ins. Company Name & Address

Patient Name
Subscriber Name
Subscriber Address
Ins. Company Name & Address
Understanding your dental insurance coverage can be quite challenging; our goal is to assist you in maximizing your benefits.
We care for patients from many different companies. Each company pays an insurance premium for specific coverage, which fits the company budget. Each plan is slightly different in its covered services.

We encourage you to become familiar with your policy exclusions, deductibles and required co-payments.

Our courtesy service to you includes:

  • Filing your insurance within 24 hours of your visit and requesting payment of your benefit to our office.
  • Electronically filing your insurance for short turn around.
  • Assisting you to the best of our ability to help maximize your benefits.
  • Re-filing your insurance, a second time within 60 days.
  • Following the American Dental Association guidelines for coding procedures and filing insurance.

Our expectations of you as the owner of the policy:
  • Payment of fees not covered by your insurance plan at the time the service is delivered.
  • Understanding that the insurance policy belongs to you and we have no leverage to obtain payment from your insurance carrier.
  • Realizing that dental insurance policies restrict payment for some services, use restricted fee schedules (called Usual and Customary Rates) and exclude some procedures based on prior conditions or length of time on the plan. All restrictions are based on the premium paid for insurance not our fees or recommended treatment.
  • Taking responsibility for payment if the insurance does not pay our office within 90 days.
  • Keeping our office informed of any changes in your insurance coverage or employment.

Thank you for your cooperation with your dental insurance coverage. Please sign the space below to authorize assignment of benefits and provide us with your insurance card to copy for our file.

I hereby authorize Shoreline Dental Care L.L.C. to release to my insurance company information acquired during my dental care. I hereby authorize benefits to be paid directly to Shoreline Dental Care L.L.C. I understand that I am responsible for any unpaid balance.