Insurance Verification Form For Oral Surgery Dental - Oms Associates
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1INSURANCE VERIFICATION FOR ORAL SURGERY
Today’s Date: _______________________ Time: ____________ TC: _____________________ Date Verified: _____________________
Patient’s Name: ___________________________ DOB: ____________ Relationship: _______________ SS: ________________________
Member’s Name: _______________________________ DOB: _____________Member ID#/SS: _________________________________
Employer: ___________________________________________________Group #____________________________________________
Insurance Company Name:___________________________________________________ Plan: __________________________________
INSURANCE PAYOR NUMBER______________________________ ACCEPTS ATTACHMENTS? _______YES
________ NO
Claim Address: _____________________________________ City: ____________________ State: _________ Zip Code: ______________
Telephone#: ______________________________________ Name of Insurance Person: _________________________________________
In Network Benefits? Yes _______ No ________ Out of Network Benefits? Yes _______ No ________
Benefit Coverage:
Employee: ________ Employee and Spouse: _________ Family: ____________ Other: ____________
Effective Date: ______________ Policy Still in Effect? Yes _______ No ________ Termed? ____________ Calendar? Yes _____ No _______
DENTAL
Individual MAX $: ____________________ Individual Max $ Used: _________________ Individual Max $ Left: ______________________
Individual DED $: _________________ Individual Ded Met $: ______________ Family Ded $: ___________ Family Ded Met $: __________
Waiting Period? Yes _______ No ________ Has it Been Met? Yes _______ No ________
Preventative: __________%
Basic: ___________%
Major: ______________%
Date of Last: FMX: __________________________ Pano: _________________________ Exam; _________________________________
9310
0140
Frequency: FMX/Pano:
1 in 3: _____ 1 in 5: _____ No history: ________
Coverage
Frequency
Add’l Codes: Exclusions and Limitations
Extractions & Impactions
0322: CT Scan_____________________________________
7110
7111
7120
6010: Implants _____________________________________
7140
7210
7220
7280/7283 access unerupted/plcmnt of device; ______________
7230
7240
7241
9230: Nitrous Gas:___________________________________
7250
9241/9242: Conscious IV Sedation______________________
IV SEDATION-IS IT SUBJECT TO REVIEW? Yes _______ No ________
9220 (Deep IV): _________________________________________________________________________________________________
9221 (Deep IV): _________________________________________________________________________________________________
PRE DETERMINATION REQUIRED? Yes _______ No ________ SUBJECT TO MEDICAL FIRST?
Yes _______ No ________
Comments: _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
__________________________________________________________________________________
____________________
____________________________________________________________________________________________________
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