
Patient Intake Form
Your Smile Matters—So Does Your Health
Service Description
My Smile Insured is here to advocate for you—helping you understand and use your medical insurance for necessary dental care. By working together, we can build the strongest case for your treatment and help you access the care you deserve.”
Cancellation Policy
My Smile Insured – Advocacy Service Policy My Smile Insured provides patient advocacy and insurance support services to help you understand and navigate your medical insurance benefits for medically necessary dental treatment. Our role is to guide, educate, and assist in building a strong case for medical necessity in collaboration with you and your dental provider. By using our services, you acknowledge that the best outcomes are achieved through active participation and communication between you, your provider, and My Smile Insured. No Guarantee of Coverage My Smile Insured does not guarantee insurance coverage, payment, or approval of any claim, preauthorization, or appeal. All insurance benefits and determinations are made solely by your insurance carrier based on your individual plan and policy. Patient Responsibility You agree to provide accurate and complete information regarding your medical history, insurance, and treatment. You are financially responsible for any services not covered by your insurance. Timely communication and documentation are essential to achieving the best possible outcome. Scope of Services Our services may include insurance benefit analysis, medical necessity guidance, documentation support, coordination with providers, and advocacy for claims and appeals. We do not provide legal advice, medical diagnosis, or clinical care. HIPAA Privacy Policy My Smile Insured is committed to protecting your personal health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). By engaging our services, you authorize us to collect, use, and securely share your information with healthcare providers and insurance carriers as needed to support your case. All information is handled with strict confidentiality and only used for purposes related to your care and advocacy. Communication Consent By providing your contact information, you consent to receive communications from My Smile Insured via phone, email, and text regarding your case and next steps. Acknowledgment By using our services, you confirm that you have read, understand, and agree to this policy.
Contact Details
833-813-9468
info@mysmileinsured.com
