Insurance Verification 2020

Employee: _____________________
INSURANCE VERIFICATION
Date: _______________ Rep: _________________________
Prev:____________ Diag:___________ Basic:___________
Ref # for Call: ______________________________________ Is the Diagnistic subject to the Ded? YES NO
Patient Name: ______________________________________ Is Preventive Subject to annual max? YES NO
Patient DOB: _______________________________________ Exams: _______________________ HX: ________________
Insured Name: ______________________________________ Prophy: ______________________ HX: ________________
Insured DOB: ______________________________________ BW: _________________________ HX: ________________
Insured ID/SS#: ____________________________________ D0220 __________ D0140 __________ D0150 __________
Employer: _________________________________________ FREQ: __________ FREQ: __________ FREQ: __________
Group #: __________________________________________ D9944: __________ D9310: __________
Ins. Company: ______________________________________
Ins. Phone#: _______________________________________ ENDO: ______________
Ins. Address: _______________________________________ D3920(Hemi) _________ D3346 (RT) ___________
__________________________________________________ D3347 (RT) __________ D3348 (RT) ___________
D3410 (Apico) _______ D3421 _______ D3425 ________
Payer ID: ____________ Fee Schedule: _________________
What kind of plan is it? ______________________________ PERIO: _____________
Effective Date: _____________________________________ D4260 (Perio Surg):_______ FREQ:_________ HX:_______
Family Coverage: YES NO D4341:_________________ FREQ:_________ HX:________
Calendar Year OR Fiscal Year: ____________ ______ Quads ______ 30 or 90 day wait for D4910:________
Yearly Max: __________ Remaining: ____________ D4346: _____________ FREQ: __________ HX:__________
Ded: _________________ Ded met: _______________ D4355: _____________ FREQ: __________ HX:__________
Can Exam D0150 be Done same day with D4335?_________
Missing Tooth Clause: ______ Roll Over Benefit: ________ D4910: _____________ FREQ: __________ HX: _________
Waiting Period: __________ How Long? ______________ Subject to ded: ___________
Pending Claims? ____________________________________ Is D4910 Either _____ OR In Addition to a reg prophy? ____
Are assignment of benefits accepted? ____________________
Coordination of Benefits? _____________________________ ORAL SURGERY: ______________
D7140: ___________ D7250:__________ D7210:_________
Downgrade: Composite: _____ FREQ: _____ Crowns: _____ D7240: ___________ D7241:__________ D7230:_________
Replacement: _______________ Paid on: ________________ D7510: ___________ M/D D7960:__________
Does OS have a Freq:__________________________
Do Exams share frequency? YES NO
PANO/FMX: ___________________ Hx: ______________ MAJOR: ________________ IMPLANTS:_____________
Pano and FMX share Frequency? __________ ____________ D2950: ______ D2954: ______ D2962:______ D6056:_____
D6010: _______ D6104(Bone Graft):_______ D6058:______
Fluoride: _________% Freq: __________ Age: ________ D4249: ___________ D2740:__________
Sealants: _________% Freq: __________ Age: ________ Can 4249 be done same day as: 2954 _______ 2740 ________
Teeth Allowed: _____________________________________ How many day wait for D2740__________ / D2954________
Space Mnt: ____________ Freq: __________ Age: ________
Employee: _____________________
INSURANCE VERIFICATION
Ortho %: _________ Age Limit: _________
Subscriber & Spouse? _______ Sep Ded: _______
Ortho Max: __________ Remaining:_________
Pays: ____ Automatically ____ Manually ____Monthly ____Semi Annually ____ Quarterly
What is the initial payment? ___________________
MINOR TREATMENT TO CONTROL HARMFUL HABIT
D8210: _______ D8220: _______
OTHER ORTHODONTIC SERVICES
D8660_______ D8670: _______ D8680: _______ D8681: ______
D8690: _______ D8691: _______ D8692: _______ D8693:_______
D8694: _______
INTERCEPTIVE ORTHO TREATMENT
D8050: _______ D8060:______
COMPREHENSIVE ORTHO TREATMENT
D8040: _______ D8070:_______ D8080:_______ D8090:______

Insurance Verification 2020

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Insurance Verification 2020

Загружено:

Авторское право:

Доступные форматы

Employee: _____________________

Ortho %: _ Age Limit: _

Subscriber & Spouse? _ Sep Ded: _

Ortho Max: __ Remaining:_

What is the initial payment? ___________________

MINOR TREATMENT TO CONTROL HARMFUL HABIT

D8210: _ D8220: _

OTHER ORTHODONTIC SERVICES

D8660___ D8670: _ D8680: _ D8681: __

D8690: ___ D8691: _ D8692: _ D8693:___

INTERCEPTIVE ORTHO TREATMENT

D8050: _ D8060:

COMPREHENSIVE ORTHO TREATMENT

D8040: ___ D8070:_ D8080:_ D8090:__

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