Dental Insurance Verification Form Template printable pdf download

SUBSCRIBER/PATIENT

If patient answered YES, get the following information:

SUBSCRIBER NAME:

SUBSCRIBER S.S. #

SUBSCRIBER D.O.B:

SUBSCRIBER ID #

INSURANCE GROUP #

GROUP NAME:

PATIENT'S NAME:

PATIENT'S DOB:

INSURANCE CO. NAME:

Insurance Phone #

B. INSURANCE PLAN BENEFITS

DATE INSURANCE VERIFIED: ______________________

SPOKE TO: ______________________________

EFFECTIVE DATE OF SERVICE:

BENEFIT YEAR:

□ CALENDAR

ARE FEES:

□ Reasonable & Custom

□ FISCAL

□ Contracted

ANNUAL MAXIMUM: $ _____________ Used?:

DED APPLIES:

□ PREVENTATIVE

DEDUCTIBLE MET? □ YES

□ BASIC AND MAJOR

□ NO

□ ALL

INDIVIDUAL DEDUCTIBLE: $ _______________

COINSURANCE AMOUNTS:

Separate MAX for Prev/Diagnostic Services?

PREVENTATIVE SERVICES COVERED AT: %

PERIO SERVICES COVERED AT: %

Post & Core (D2954):

BASIC SERVICES COVERED AT: %

ENDO SERVICES COVERED AT: %

FMD (D4355):

MAJOR SERVICES COVERED AT: %

ORAL SURGERY COVERED AT: %

Crown Buildup (D2950):

Bonegraft 7953 (Ok same day as EXT?):

C. FREQUENCY LIMITATIONS

HISTORY (Last Date of Procedure):

Prophy :

*Include DOS for FMX/PANO if on file

COMP EXAM (D0150):

BWX (D0274):

LIMITED EXAM (D0140):

FMX (D0210):

PERIODIC EXAM (D0120):

PANO (D0330):

PERIO EVAL (D0180):

COMPOSITES:

Are composites downgraded to Amalgam? □ YES □ NO

Arestin (4381) :

Waiting Period for Major Work? □ YES □ NO

Missing Tooth Clause? □ YES □ NO

Scaling and Root Planning: □ 2 Quads per Visit □ 4 Quads per visits

Are Occlusal Guards Covered? □ YES □ NO

Frequency: _____________________________________ (OK SAME DAY AS 1110?)

Covered Under? □ BASIC □ MAJOR

Perio Maintanence: __________________ □ In addition □ Either/Or

For Bruxism Only? □ YES □ NO

Frequency: __________

Perio Covered Under? □ Prev/Diag □ Basic

Are Implants covered? □ YES □ NO

Ortho Coverage?

Codes: 6010: 6057:

6059:

Dental Insurance Verification Form Template

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