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Oral Surgery Insurance Verification Form

Patient Insurance Information and Verification Checklist

Oral Surgery

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Last updated: Mar 24, 2025

Patient Information

  • Full Name: ____________________
  • Date of Birth: //___
  • Insurance ID #: ________________
  • Group #: ____________________

Primary Insurance Details

  • Insurance Company: ________________
  • Policy Holder Name: ______________
  • Relationship to Patient: ___________
  • Employer: _______________________

Coverage Verification Checklist

General Coverage

  • [ ] Annual Maximum: $_________
  • [ ] Remaining Benefits: $_________
  • [ ] Deductible: $_________
  • [ ] Deductible Met: $_________

Specific Procedures

  • [ ] Surgical Extractions (D7210)
    • Coverage %: _____
    • Patient Portion: $_____
  • [ ] Impacted Teeth (D7220-D7240)
    • Coverage %: _____
    • Patient Portion: $_____
  • [ ] Bone Grafting (D7953)
    • Coverage %: _____
    • Patient Portion: $_____

Authorization Requirements

  • [ ] Pre-authorization Required?
  • [ ] X-rays Required?
  • [ ] Narrative Required?

Verification Details

  • Date Verified: //___
  • Staff Member: ________________
  • Reference #: ________________

Notes

Disclaimer

Verification of benefits is not a guarantee of payment. Final coverage determination will be made when the claim is processed.

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