Insurance Verification Form

Insurance Verification Form

Instructions: Prior to your appointment, please call your insurance company, print and complete this form in its entirety and fax or e-mail back to us.

Patient Insurance Verification Form

Primary Insurance

Please Ask Your Insurance Company Representative the Following Questions

Do we have a deductible?
Is the benefit paid to my Orthodontist automatically? Please check below:
Are spouse and employee covered?

Verified by: (Name of person from insurance company you spoke with)

I understand that estimates benefits quoted to me and/or Dr. Gragg by my insurance company are not a guarantee of payment and that I am responsible for any and all fees not paid by my insurance company.



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Gragg Orthodontics

  • Morganton - 303 S. Green St., Suite 201, Morganton, NC 28655 Phone: 828-438-8998 Fax: 828-438-8898
  • Lenoir - 509 Harper Ave. S.W., Lenoir, NC 28633 Phone: 828-438-8998 Fax: 828-438-8898

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