Orthodontic Insurance Verification Form

Patient Information

• Full Name: _______________
• Date of Birth: //___
• Insurance ID: _______________
• Group Number: _______________

Primary Insurance Information

• Insurance Company Name: _______________
• Policy Holder Name: _______________
• Policy Holder DOB: //___
• Employer: _______________
• Relationship to Patient: _______________

Insurance Verification (Office Use Only)

Orthodontic Benefits

• Lifetime Maximum: $_______________
• Remaining Benefit: $_______________
• Age Limit: _______________
• Adult Coverage: □ Yes □ No

Coverage Details

• Deductible: $_______________
• □ Met □ Not Met
• Coverage Percentage: ____%
• Prior Authorization Required: □ Yes □ No

Payment Structure

• Initial Payment: $_______________
• Monthly Estimated Payment: $_______________

Exclusions & Limitations

• Waiting Period: _______________
• Pre-Existing Conditions: _______________
• Other Limitations: _______________

Verification Details

• Date Verified: //___
• Verified By: _______________
• Reference Number: _______________

Note: Benefits quoted are not a guarantee of payment. Final coverage determination will be made when the claim is processed.