Dental Insurance Verification Form

Patient Information

• Full Name: ________________________
• Date of Birth: //___
• Patient ID: ________________________
• Contact Number: ___________________

Primary Insurance Information

• Insurance Company: ________________
• Policy Holder Name: _______________
• Policy Holder DOB: //___
• Member ID: _______________________
• Group Number: ____________________
• Insurance Phone: __________________

Coverage Details

Plan Type:

• □ PPO
• □ HMO
• □ Other: _________________________

Benefits Verification:

• Annual Maximum: $________________
• Remaining Benefit: $______________
• Deductible: $____________________
• Amount Met: $___________________
• Preventive Coverage: _______%
• Basic Services: _______%
• Major Services: _______%

Verification Details

• Date Verified: //___
• Staff Member: ___________________
• Reference #: ____________________

Special Notes

• Waiting Periods: ________________
• Exclusions: _____________________
• Pre-authorization Requirements:

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Office Use Only

□ Benefits Verified □ Patient Notified □ Scanned to Chart

Staff Signature: ___________________ Date: //___