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Dr. Michael Yeh DDS New Patient Case

Notice: This form is intended for use by the provider and their specifically designated team members only. If you are not the provider or an authorized team member, you must complete a Business Associate Agreement (BAA) form.

Practice & Provider Contact Information

Patient Contact Information

Enter Secret Code from Patient Agreement

Need Help?

Upload Patient Agreement (Optional)

Upload Treatment Plan Details

Driver's License/ID Card (Front and Back)

Medicare /Medical Card (Front and Back)

Dental Insurance (Front and Back)

Any Other Insurance/Coverage (Front and Back)

Additional Notes

Acknowledgement: By submitting this information, you acknowledge that you have reviewed all the information before submitting and that you understand that this means you are submitting a claim as an authorized party of the above-named practice and provider. You will receive a copy of this claim to your email. If you do not see it or need to add another email, please email [email protected] for assistance. To add another email, include the name of your practice, provider, and the email you would like to add.
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