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Dear Parents,

If you have dental insurance coverage we will be happy to file your claim forms as a courtesy, but to do so we need all the correct insurance information contained on the form below. Please bring the filled out copy to your child’s appointment. If you first appointment is via Tele-dentistry please email these forms to Do not forget your insurance card if you have insurance.

IMPORTANT NOTE – We do not know the specific benefits that your dental insurance provides and we recommend that you contact them directly to find out what is or is not covered. Our practice is not an HMO or PPO insurance contractor and we are considered “out of network.” What this means is that you are responsible for any co-payments and/or  any remaining balance after insurance pays benefits. Also, we regret that we do not accept Medical insurance.

Again, please contact your insurance company for the best information about your benefits, but if you have any other questions about your child’s treatment plan or other medical issues, please contact our office at 818.465.7545.

Thank you,

Lasky Pediatric Dental Group

Insurance Form

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