Thanks, your survey is in

To speed things up, upload your insurance card and photo ID below. Our team can start your benefits check before your treatment coordinator calls you during office hours.

Have these ready · about 2 minutes

Your medical insurance card, front
Your medical insurance card, back
A photo ID, such as a driver’s license

A clear photo from your phone works fine. Please don’t text or email these. Upload them here instead.

Full Name

Email *

Thanks for completing your survey! One of our treatment coordinators will reach out during office hours.

To get a head start, upload photos of the front and back of your medical insurance card and your driver's license here:

The sooner we have these, the sooner we can check what your medical benefits will cover.

— My Harmony Dentistry

559 W Twincourt Trail Ste 606, St. Augustine FL 32095

Medical Billing Card Front *

Medical Billing Card Back *

Drivers License/ID *

I confirm these documents are mine, or that I'm authorized to submit them, and I consent to My Harmony Dentistry using them to verify my identity and insurance benefits.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from My Harmony Dentistry at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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What happens next

1

A coordinator calls youDuring office hours, to go over your options in plain language.

2

We check your benefitsOur team reviews what your plan shows and helps with the next steps.

3

You decide, no pressureAny next step is your choice.

Coverage depends on your plan and medical necessity. Submitting documents does not guarantee coverage or treatment.

Trouble uploading?

No problem. Call us and we’ll help you finish. Please don’t send these photos by text or email.