dentalimplantcheck.khassa.com
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https://dentalimplantcheck.khassa.com/
Submission: On September 20 via api from US — Scanned from DE
Submission: On September 20 via api from US — Scanned from DE
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<form method="post" id="orderform" action="#">
<div class="container" id="contact">
<div id="contact_results"></div>
<h3 class="section-subtitle upper bold text-center">DENTAL IMPLANTS THROUGH MEDICAL INSURANCE</h3>
<div class="row">
<div id="contact_form">
<div class="col-sm-10 col-sm-offset-1"> </div>
<div class="col-sm-10 col-sm-offset-1"> </div>
<p class="hidden-xs"> </p>
<div class="col-sm-10 col-sm-offset-1 "> </div>
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<!--<h3 class="blue">Did you know that under certain circumstances, your medical insurance may provide coverage for dental implants and related procedures. Usually, such coverage is due to health issues caused by medical issues/medications. Some examples of such issues are:</h3> -->
<p class="p_text">Did you know that under certain circumstances, your medical insurance may provide coverage for dental implants and related procedures. Usually, such coverage is due to health issues caused by medical issues/medications.
Some examples of such issues are:</p>
<p class="p_text"><b>1.</b> When a medical condition causes significant tooth deterioration/bone loss.</p>
<p class="p_text"><b>2.</b> When certain medications that are used to address a medical condition cause significant damage to teeth/bone loss.</p>
<p class="p_text"><b>3.</b> When certain conditions such as radiation therapy for cancer causes significant tooth deterioration/bone loss.</p>
<p class="p_text"><b>4.</b> When certain medical procedures (Example a gastric bypass) result in issues which cause significant tooth deterioration/bone loss.</p>
<p class="p_text"> </p>
<h3 class="blue">Please fill form below to determine if your medical insurance will potentially cover dental implants/bone grafts due to medical necessity.</h3>
</div>
<div class="col-sm-10 col-sm-offset-1"> </div>
<div class="col-sm-10 col-sm-offset-1"> </div>
<div class="col-sm-10 col-sm-offset-1 ">
<label><b>Your Medical Insurance is</b></label>
</div>
<div class="col-sm-2 col-sm-offset-1"> <input type="radio" id="ins1" name="ins" onchange="on_change(this)" value="HMO">HMO</div>
<div class="col-sm-2"> <input type="radio" id="ins2" name="ins" onchange="on_change(this)" value="PPO">PPO</div>
<div class="col-sm-2"> <input type="radio" id="ins3" name="ins" onchange="on_change(this)" value="EPO">EPO</div>
<div class="col-sm-4"> <input type="radio" id="ins4" name="ins" onchange="on_change(this)" value="I do not know"> I do not know. </div>
</div>
<div class="col-sm-10 col-sm-offset-1 text-center"> </div>
<div class="col-sm-10 col-sm-offset-1 text-center" id="text" style="display:none;color:red;font-size:18px !important; ">
<b>Sorry, but HMO and EPO Medical Plans do not cover Dental Implants/Bone Grafts.</b>
</div>
<div class="col-sm-10 col-sm-offset-1" id="text1" style="display:none">
<div class="col-sm-10 col-sm-offset-1">
<label>Please select your insurance </label>
</div>
<div class="col-sm-10 col-sm-offset-1"> </div>
<div class="col-sm-6 col-sm-offset-1">
<div class="form-group">
<label><b>(A)</b> Primary Insurance</label>
<select name="insname" id="insname" class="form-control" required="">
<option value="">Select</option>
<option value="Aetna">Aetna</option>
<option value="Ameritas">Ameritas</option>
<option value="BCBS-Anthem">BCBS-Anthem</option>
<option value="Blue Cross Blue Shield">Blue Cross Blue Shield</option>
<option value="Cigna">Cigna</option>
<option value="Humana">Humana</option>
<option value="Metlife">Metlife</option>
<option value="Oscar">Oscar</option>
<option value="Other">Other</option>
<option value="Scott White">Scott White</option>
<option value="United Healthcare">United Healthcare</option>
</select>
</div>
</div>
<div class="col-sm-4 " styles="display:none;" id="ins9" style="display: none;">
<div class="form-group">
<label>Other Primary Insurance Name?</label>
<input type="text" name="otherinsname" id="otherinsname" maxlength="20" class="form-control otherinsnameinfo">
</div>
</div>
</div>
<!-- other insurance -->
<div class="col-sm-10 col-sm-offset-1" id="text2" style="display:none">
<div class="col-sm-10 col-sm-offset-1">
</div>
<div class="col-sm-10 col-sm-offset-1"> </div>
<div class="col-sm-6 col-sm-offset-1">
<div class="form-group">
<label><b>(B)</b> Secondary Insurance (Optional)</label>
<select name="insname1" id="insname1" class="form-control">
<option value="">Select</option>
<option value="Aetna">Aetna</option>
<option value="Ameritas">Ameritas</option>
<option value="BCBS-Anthem">BCBS-Anthem</option>
<option value="Blue Cross Blue Shield">Blue Cross Blue Shield</option>
<option value="Cigna">Cigna</option>
<option value="Humana">Humana</option>
<option value="Metlife">Metlife</option>
<option value="Oscar">Oscar</option>
<option value="Other">Other</option>
<option value="Scott White">Scott White</option>
<option value="United Healthcare">United Healthcare</option>
</select>
</div>
</div>
<div class="col-sm-4 " styles="display:none;" id="ins7" style="display: none;">
<div class="form-group">
<label>Other Secondary Insurance Name?</label>
<input type="text" name="otherinsname1" id="otherinsname1" maxlength="20" class="form-control otherinsnameinfo1">
</div>
</div>
</div>
<div class="col-sm-10 col-sm-offset-1"> </div>
<div class="col-sm-10 col-sm-offset-1"> </div>
<div class="col-sm-5 col-sm-offset-1">
<div class="form-group">
<label>First Name </label>
<input type="text" name="name" id="name" maxlength="60" class="form-control" required="">
</div>
</div>
<div class="col-sm-5">
<div class="form-group">
<label>Last Name </label>
<input type="text" name="lname" id="lname" maxlength="60" class="form-control" required="">
</div>
</div>
<div class="col-sm-5 col-sm-offset-1">
<div class="form-group">
<label>Phone </label>
<input type="tel" name="phone" id="phone" class="form-control" required="" oninput="this.value = this.value.replace(/[^0-9.]/g, '').replace(/(\..*?)\..*/g, '$1').replace(/^0[^.]/, '0');" maxlength="15" minlength="10">
</div>
</div>
<div class="col-sm-5">
<div class="form-group">
<label>Email </label>
<input type="email" name="email" id="email" maxlength="80" class="form-control" required="">
</div>
</div>
<div class="col-sm-5 col-sm-offset-1">
<div class="form-group">
<label>Address </label>
<input type="text" name="address" id="address" class="form-control" required="" maxlength="80">
</div>
</div>
<div class="col-sm-5">
<div class="form-group">
<label>Apt/Suite </label>
<input type="text" name="apt" id="apt" maxlength="80" class="form-control">
</div>
</div>
<div class="col-sm-4 col-sm-offset-1">
<div class="form-group">
<label>City </label>
<input type="text" name="city" id="city" maxlength="30" class="form-control" required="">
</div>
</div>
<div class="col-sm-3 ">
<div class="form-group">
<label>State</label>
<select name="state" id="state" class="form-control" required="">
<option value="">Select State</option>
<option value="1">Alabama</option>
<option value="2">Alaska</option>
<option value="3">Arizona</option>
<option value="4">Arkansas</option>
<option value="5">California</option>
<option value="6">Colorado</option>
<option value="7">Connecticut</option>
<option value="8">Delaware</option>
<option value="9">District Of Columbia</option>
<option value="10">Florida</option>
<option value="11">Georgia</option>
<option value="12">Hawaii</option>
<option value="13">Idaho</option>
<option value="14">Illinois</option>
<option value="15">Indiana</option>
<option value="16">Iowa</option>
<option value="17">Kansas</option>
<option value="18">Kentucky</option>
<option value="19">Louisiana</option>
<option value="20">Maine</option>
<option value="21">Maryland</option>
<option value="22">Massachusetts</option>
<option value="23">Michigan</option>
<option value="24">Minnesota</option>
<option value="25">Mississippi</option>
<option value="26">Missouri</option>
<option value="27">Montana</option>
<option value="28">Nebraska</option>
<option value="29">Nevada</option>
<option value="30">New Hampshire</option>
<option value="31">New Jersey</option>
<option value="32">New Mexico</option>
<option value="33">New York</option>
<option value="34">North Carolina</option>
<option value="35">North Dakota</option>
<option value="36">Ohio</option>
<option value="37">Oklahoma</option>
<option value="38">Oregon</option>
<option value="39">Pennsylvania</option>
<option value="40">Rhode Island</option>
<option value="41">South Carolina</option>
<option value="42">South Dakota</option>
<option value="43">Tennessee</option>
<option value="44">Texas</option>
<option value="45">Utah</option>
<option value="46">Vermont</option>
<option value="47">Virginia</option>
<option value="48">Washington</option>
<option value="49">West Virginia</option>
<option value="50">Wisconsin</option>
<option value="51">Wyoming</option>
</select>
</div>
</div>
<div class="col-sm-3">
<div class="form-group">
<label>Zip Code </label>
<input type="text" name="zip" id="zip" class="form-control" required="" oninput="this.value = this.value.replace(/[^0-9.]/g, '').replace(/(\..*?)\..*/g, '$1').replace(/^0[^.]/, '0');" maxlength="10">
</div>
</div>
<div class="col-sm-10 col-sm-offset-1">
<input type="checkbox" value="1" name="agree" required=""> I agree for Elite Medical Management and its affiliates to send me an Email address above to verify my Medical Insurance for Dental Benefits.
</div>
<div class="col-sm-10 col-sm-offset-1"> </div>
<div class="col-sm-10 col-sm-offset-1 text-center" id="text3" style="display:none">
<button id="submit_btn" type="submit" name="addUIser" class="btn btn-lg btn-custom">Submit</button>
</div>
</div>
</div>
</form>Text Content
DENTAL IMPLANTS THROUGH MEDICAL INSURANCE Did you know that under certain circumstances, your medical insurance may provide coverage for dental implants and related procedures. Usually, such coverage is due to health issues caused by medical issues/medications. Some examples of such issues are: 1. When a medical condition causes significant tooth deterioration/bone loss. 2. When certain medications that are used to address a medical condition cause significant damage to teeth/bone loss. 3. When certain conditions such as radiation therapy for cancer causes significant tooth deterioration/bone loss. 4. When certain medical procedures (Example a gastric bypass) result in issues which cause significant tooth deterioration/bone loss. PLEASE FILL FORM BELOW TO DETERMINE IF YOUR MEDICAL INSURANCE WILL POTENTIALLY COVER DENTAL IMPLANTS/BONE GRAFTS DUE TO MEDICAL NECESSITY. Your Medical Insurance is HMO PPO EPO I do not know. Sorry, but HMO and EPO Medical Plans do not cover Dental Implants/Bone Grafts. Please select your insurance (A) Primary Insurance Select Aetna Ameritas BCBS-Anthem Blue Cross Blue Shield Cigna Humana Metlife Oscar Other Scott White United Healthcare Other Primary Insurance Name? (B) Secondary Insurance (Optional) Select Aetna Ameritas BCBS-Anthem Blue Cross Blue Shield Cigna Humana Metlife Oscar Other Scott White United Healthcare Other Secondary Insurance Name? First Name Last Name Phone Email Address Apt/Suite City State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code I agree for Elite Medical Management and its affiliates to send me an Email address above to verify my Medical Insurance for Dental Benefits. Submit