DENTAL INSURANCE VERIFICATION FORM

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DENTAL INSURANCE VERIFICATION FORM Powered By Docstoc
					NPI# 1508858846              TAX ID# 201692528                      Date :_______________

                                  INSURANCE BREAKDOWN FORM

PATIENT:_____________________________         DOB:_______________________

INSURED:____________________________          DOB:_______________________

INSURED SS#:_________________________         EMPLOYER:______________________

PERSON SPOKE TO:________________________      EFFECTIVE DATE:_________________

INSURANCE PHONE#_____________________         GROUP #____________________

INSURANCE COMPANY:___________________         PAYOR ID #___________________

ANNUAL DEDUCTIBLE:___________________         MET?_______________________

ANNUAL MAXIMUM:____________________           AMT USED:___________________

PREV_________% DED APPLIES YES NO

BASIC________ % DED APPLIES YES NO      POSTERIOR COMP DOWNGRADED? YES NO

MAJOR_______ % DED APPLIES YES NO

OCCLUSAL GUARD (9940) YES NO ______% ______________VELSCOPE (0431) YES NO ______%

PROPHY FREQ_____      X PER_______YEAR_______________HISTORY________________

EXAM FREQ_______      x PER_______YEAR_______________HISTORY________________

BWX FREQ________      X PER_______YEAR_______________HISTORY________________

SRP(4341)________     X PER_______YEAR_______________ALL 4 QUADS SAME DATE: YES NO

FMX/PANO _______X PER_______ ROLLING YEARS/MOS      HISTORY________________

SEALANTS________X PER________AGE LIMIT________HISTORY______________           P   B   M

IMPLANTS(6010) YES NO ________________________________________

ENDO B M       PERIO MAINT(4910) P B M ALTERNATING/ADDITIONAL PERIO HX NEEDED? YES NO

ORAL SURGERY B M      CROWN B/U      YES NO PAY ON SEAT DATE?______

MISSING TOOTH YES NO WAITING PERIOD YES NO           REPLACEMENT CLAUSE__________________

				
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