DENTISTS BENEFITS INSURANCE COMPANY

Created exclusively for dentists by dentists, DBIC is committed to helping you and your staff. Our trained professionals serve as a resource for your practice, and we are happy to assist with dentist insurance questions, proper documentation, risk management services and much more.

Risk management forms

General

• Authorization for Release of Information for Employment Purposes
• Authorization to Disclose Healthcare Information
• Dismissal Letter
• Insurance Verification
• Patient Information
• Patient Information (Dental Questionnaire)
• Periodontal Chart

Claim forms

To submit a claim, contact our claims department at 800-452-0504, or complete the appropriate claim form below and submit online.

• Property Loss
• Liability Loss
• Quick Claim Form

Consent forms

• Appliance Release Payment Agreement
• Consent for Amalgam Replacement Procedures
• Consent for Bisphosphonate
• Consent for Bleaching Teeth
• Consent for Composite Fillings
• Consent for Cosmetic Treatment
• Consent for CT
• Consent for Crown and Bridge Prosthetics
• Consent for Dental Implants
• Consent for General Dentistry
• Consent for Extraction
• Consent for Oral Surgery
• Consent for Nitrous Oxide
• Consent for Occlusal Equilibration
• Consent for Peridontal Cleaning
• Consent for Periodontal Disease
• Consent for Periodontal Procedures Scaling Root Planing
• Consent for Pulpotomy
• Consent for Root Canal Treatment
• Consent for Sealants
• Consent for Silver Amalgam Restorations
• Dental History & Consent for Treatment
• Informed Consent Permission Form
• Kinship Caregivers Informed Consent Declaration for Minors
• Refusal of Recommended Treatment

We would like to gratefully acknowledge the assistance from Schatz and Company and Omsnic with the consent forms