Precision Implant Dentistry - (800) 797-0406

Medicare Pre-Qualification

In order for us to accurately determine the amount of the Medically Necessary portion of your procedure that Medicare may cover, and to estimate your out-of-pocket costs we will require the information in the following form.

Before you begin to complete the form you will need to have the following items ready to upload:

  • A copy of your Medicare Card
  • A copy of any Supplemental Insurance Card
  • A copy of your drivers license or state ID
  • A copy of a recent panoramic dental x-ray
  • A copy of a Physicians 6 month medical report

Please complete the form as completely as possible so we can provide accurate information, and streamline the process. If you are unable to complete the form please call our Medicare intake team @ 702-641-7111 for assistance

Dr. Golpa and his team are true perfectionists in every way. You have to see it to believe it.
— Ralph