Page 1 of 1
New Patient Case
You are submitting a claim for Broadway Dental
Practice & Provider Contact Information
*
*
*
*
Patient Contact Information
*
*
*
Patient Agreement
Two Options: 1. Send this online link for patient to sign and confirm it's been completed
https://go.predentalcheck.com/65agree
2. Download Sign and Upload the Form
https://drive.google.com/file/d/1h61kMfsOy19pFuPIC62qYfgkuO_6kXdF/view?usp=sharing
Upload Patient Agreement
Click to choose a file or drag here
Upload Treatment Plan Details
*
Click to choose a file or drag here
Driver's License/ID Card (Front and Back)
Click to choose a file or drag here
Medicare /Medical Card (Front and Back)
Click to choose a file or drag here
Dental Insurance (Front and Back)
Click to choose a file or drag here
Any Other Insurance/Coverage (Front and Back)
Click to choose a file or drag here
Submit
