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