Insurance Verification Form printable pdf download

INSURANCE VERIFICATION FORM

As a courtesy to our patients, we file and accept payment from your insurance company. We are providing you

with this form and ask that you call your insurance company to ask them the following questions so we can

estimate what your payment should be at the time of service. We understand that calling your insurance company

& filling out this form may be inconvenient for you. Please understand that it is our way of educating our patients

as to what their plan does and does not cover. Dental insurance is intended to cover some, but not all, of the cost

of your dental care.

We cannot stress enough that insurance payment is not, and has never been, a

guideline for quality

care.

Policy Owner’s Name _____________________________Patient Name ________________________

Policy Owner’s Address (if different than pt’s) ______________________________________________

Policy Holder’s DOB ____________ SSN_________________ Relationship to Patient_______________

Policy Owner’s Employer ___________________ Ins. Co. Name/Address ________________________

_______________________________ Phone No.___________________ Group #______________

PLEASE CALL THE 1-800# ON YOUR CARD TO COMPLETE THIS FORM &

HAVE YOUR BENEFITS FAXED TO OUR OFFICE @ 828-299-0550

Calendar or fiscal year: __________ Policy effective date:__________ UCR or Fixed Rates? ____________

Yearly Maximum $________ Deductible $____ Applies to preventative? Yes__ No__

Applies to diagnostic? Yes __ No __ ___________________________________________________

Coverage: At what percentages do you cover the following?

Preventative _____% Diagnostic _____% Basic Restorative _____% Major Rest. _____%

Endo _____% Basic Perio _____% Major Perio _____% Oral Surg Basic_____% Oral Surg Major ____%

Dentures/Partials _____% Implants _____% Implant Crowns _____%

Sealants Yes __ No __ _____% Molars and Pre molars? __________ Up to what age? ____

Nitrous Oxide (code D9230) ____% Conscious sedation (code D9248) ____%

Waiting Periods? Yes __ No __ If so, how long? __________________

Missing Tooth Clause? Yes __ No __ Replacement time for partials, dentures, crowns, bridges? Yes __ No __

Do you downgrade for posterior composite fillings? Yes __ No __

FREQUENCY: Cleanings ____________Bitewings ____________FMX/Panoramic ____________

I certify that I am covered by the insurance company listed above. I assign directly to Dr. White all insurance

benefits otherwise payable to me. I hereby authorize Dr. White to release all information necessary to secure the

payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or

electronic.

_____________________________________

______________________

Signature

Date

Insurance Verification Form