Dental Insurance Verification Form
Patient Information
Patient name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Relationship to subscriber
Subscriber Information
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Insurance Information
Insurance company
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Effective date
-
Month
-
Day
Year
Date
Renewal month
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
Deductible Per Individual
Deductible Per Family
This deductible applies to:
Preventative
Basic
Major
Basic Coverage
Percentage of coverage
Is there any waiting period for basic coverage?
Yes
No
Effective Date
Describe what the coverage includes.
Major Coverage
Percentage of Coverage
Is there a waiting period for the preventative coverage?
Yes
No
Effective Date
-
Month
-
Day
Year
Date
Describe what the coverage includes.
Preventative Coverage
Percentage of Coverage
Is there a waiting period for the preventative coverage?
Yes
No
Effective Date
-
Month
-
Day
Year
Date
Prophylaxis/Exam frequency
Bitewing frequency
Fluoride varnish frequency
Is there an age limit on fluoride varnish applications?
Yes
No
What age?
Is there sealant coverage?
Yes
No
Which teeth are covered?
Is there an age limit on sealants?
Yes
No
What age?
Describe replacement on sealants
Additional notes
Submit
Should be Empty: