Insurance Verification

Financial and Insurance

Patients are finding that braces are more affordable today than ever. The cost of orthodontic treatment will depend on many factors, including the severity of the problem, its complexity and length of treatment. At Hook Orthodontics we will work with you to reach a comfortable payment plan that fits within your budget.

For your convenience, we will gladly assist you in submitting both predetermination and initial insurance claims pertaining to charges for care rendered in our office. However, please be aware our primary financial relationship is with our patients or their families and not with their respective insurance companies. Final responsibility for collection of benefits from your insurance company rests with the insured party. Our professional services are rendered and charged directly to the patient or their family and they are responsible for payment of all fees incurred.

We have been a trusted provider of United Concordia/TriCare for over 25 years and we accept most insurance carriers.

We also accept payment by Visa, MasterCard and Discover.

Your Contact Information

Your Name*

First Last

Email*

Phone Number*

Your Date Of Birth*

Loved Ones Information

Loved Ones Name*

First Last

Loved Ones Date Of Birth*

Additional Information

Insurance Information

Would you like us to verify your or a loved ones insurance benefits?*

Yes

Policy Holders Name*

First Last

Policy Holders Date Of Birth*

Policy Holders Address**

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Company's Name*

Insurance Company's Phone Number*

Member ID*

Group Number*

Subscriber relationship to client*

Insurance Verification

Financial and Insurance

Your Contact Information

Loved Ones Information

Insurance Information

Hook Orthodontics – Kailua

Hook Orthodontics – Honolulu

Hook Orthodontics – Mililani