Davenport Orthodontics
3575 Jersey Ridge Rd.
Davenport, IA 52807
Telephone: 563-355-7488
Fax: 563-355-7003
Your dental insurance is a contract between you and your insurance company. However, as a courtesy we extend to our patients, Davenport Orthodontics will assist you in the filling of your insurance claims. Please realize that not all services are covered in all insurance contracts. Most insurance benefits only cover a percentage of the professional fee.
By signing and dating this form, you authorize our office to file your insurance on your behalf and to release any information to your insurance carrier regarding the dental history and/or treatment needed or performed. You authorize payment to be sent directly to this office. This authorization constitutes “signature of file” for our computerized claim form.
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Signature date