Fillable Printable Dental Insurance Verification Form - Kansas

Dental Insurance Verification Form - Kansas

INSURANCE VERIFICATION FORM

Justin R. Dillner, D.D.S.

Patient Name: Social Security Number:

Birthdate: Relationship to Subscriber:

PATIENT INFORMATION

Subscriber Name: Social Security Number:

Birthdate: Subscriber ID Number:

SUBSCRIBER INFORMATION

Insurance Company:

Address: Phone Number:

Employer: Group Number:

Effective Date: Renewal Month: Yearly Maximum $

Deductible Per Individual $ Deductible Per Family $ This deductible applies to: Preventative Basic Major

INSURANCE INFORMATION

Does the patient have any history of SRP (D4341/D4342)? Yes No If yes, when?

Is SRP (D4341/D4342) covered? Yes No Frequency:

Can SRP (D4341/D4342) be performed on all quadrants at the same visit? Yes No

If not, what is the waiting period?

Can an adult prophylaxis and isolated SRP (D4342) be done at the same visit? Yes No

If not, what is the waiting period?

Is periodontal maintenance (D4910) covered? Yes No Frequency:

PERIODONTAL COVERAGE

Covered at % Is there a waiting period for basic coverage? Yes No Effective Date:

Includes:

BASIC COVERAGE

Covered at % Is there a waiting period for major coverage? Yes No Effective Date:

Includes:

MAJOR COVERAGE

Covered at % Is there a waiting period for preventative coverage? Yes No Effective Date:

Prophylaxis/Exam Frequency: Bitewing Frequency:

Eligible for an FMS every: years Last FMS: Eligible for an FMS now? Yes No

Flouride Varnish (D1203/D1204/D1206) Frequency:

Is there an age limit on ﬂouride varnish applications? Yes No If yes, at age:

Is there sealant (D1351) coverage? Yes No Teeth covered: Molars Premolars

Is there an age limit on sealants? Yes No If yes, at age:

Replacement on sealants is:

PREVENTATIVE COVERAGE

Are endosteal implants (D6012) covered? Yes No If yes, covered at %

Are bone replacement grafts (D7953) covered? Yes No If yes, covered at %

Are guided-tissue regeneration barriers (D4266/D4267) covered? Yes No If yes, covered at %

Are implant abutments (D6056/D6057) covered? Yes No If yes, covered at %

Are implant crowns (D6065/D6066/D6067) covered? Yes No If yes, covered at %

Is a pre-determination required prior to implant surgery? Yes No

IMPLANT COVERAGE

Are nightguards (D9940) covered? Yes No If yes, covered at %

Is nitrous oxide (D9230) covered? Yes No If yes, covered at %

Replacement on crowns and bridges is: years

Replacement on complete and partial dentures is: years

Are prior extractions covered (missing tooth clause)? Yes No

MISCELLANEOUS

Completed By: Date:

ADDITIONAL NOTES

Are orthodontics covered? Yes No If yes, covered at %

Is there an age limit on orthodontic coverage? Yes No If yes, at age:

Is there a lifetime maximum? Yes No If yes, the lifetime maximum is:

ORTHODONTIC COVERAGE