Dental Insurance Verification Form

Patient

Appt. Date

Time

Provider

Location

Subscriber & Patient Identity

Subscriber ID / Member ID Must match payer system exactly

Subscriber Name (Last, First)

Subscriber Date of Birth

Patient Date of Birth

Patient Relationship to Subscriber

Self Spouse Child Other

SSN Last 4 (if required)

⚠️ TRICARE / United Concordia: Group Number is NOT printed on the insurance card. Look up directly on the payer portal before starting verification.

Plan Identity

Financial Structure

Deductible

Individual $

Family $

Deductible Met YTD

Individual $

Family $

Annual Maximum

Individual $

Family $

Annual Maximum Used YTD

Used $

Remaining $

⚑ Flag chart if less than $150 remaining with treatment planned

Benefits & Limits

Coverage Percentages

Preventive %

Basic %

Major %

Ortho %

Ortho Lifetime Max $

Ortho Used $

Waiting Periods

Category	Waiting Period (months)	Satisfied?	Notes
Preventive		Yes No
Basic		Yes No
Major		Yes No
Orthodontic		Yes No

Frequency Limitations by CDT Code

CDT Code	Description	Plan Limit	Last Date of Service	Next Eligible
D0120	Periodic oral eval
D0150	Comprehensive oral eval
D1110	Adult prophy
D1206	Fluoride varnish
D0274	Bitewing radiographs ×4
D0210	FMX (full mouth series)
D0330	Panoramic image
D4341/D4342	SRP per quadrant

Missing Tooth Clause

Yes — applies No

Teeth affected

Radiograph Frequency Details

Type	Limit	Last DOS
Bitewings
FMX
Panoramic

Coordination of Benefits & Payer Contacts

Other Active Coverage?

Yes No

COB Designation

Primary Secondary Tertiary

COB Rule Confirmed?

Yes Pending

Secondary Payer Name / Member ID (if applicable)

Procedures Requiring Pre-Authorization

PA / Preauth Payer Contact

Phone / Fax

Portal URL

📋 SOP Timing Reminder: Best practice is T-8 (8 business days before the appointment). Minimum acceptable is T-5. T-1 verification leaves no time to resolve discrepancies before the patient is seated.

Verified by (Print Name)

Date Verified

Time

Source

Portal Voice/Phone 270/271 AI (Needletail)