Endodontic Treatment Insurance Verification Form

Patient Information

• Full Name: _________________ Date of Birth: _________________
• Insurance ID#: ______________ Group#: _______________________
• Primary Insurance Carrier: ___________________________________
• Secondary Insurance (if applicable): ___________________________

Insurance Verification Checklist

Coverage Details

• Plan Type (PPO/HMO/Other): _______________________________
• Annual Maximum: $_______________________________________
• Remaining Benefits: $____________________________________
• Deductible Amount: $____________________________________
• Deductible Met: $______________________________________

Endodontic Benefits

• Root Canal Coverage Percentage: __________________________
• Waiting Period: ________________________________________
• Pre-Authorization Required? ☐ Yes ☐ No
• Frequency Limitations: __________________________________

Additional Information

• Missing Tooth Clause: ☐ Yes ☐ No
• Build-up Coverage: ____________________________________
• Post & Core Coverage: _________________________________
• Alternative Benefits Provision: __________________________

Verification Details

• Date Verified: ___________________________________________
• Time: _________________________________________________
• Representative Name: ____________________________________
• Reference #: ___________________________________________

Notes

Staff Use Only

• Verified By: ___________________________________________
• Date: ________________________________________________