Insurance verification form

A detailed insurance verification form. It records subscriber and patient details, the insurance company and group, the date verified, and the representative spoken to. Fields cover the benefit year, fee type, annual maximum, deductibles, and coverage percentages by category. A frequency history section tracks the last dates of exams, x-rays, prophy, and perio evaluations, and specific questions address composite downgrades, waiting periods, missing tooth clauses, SRP quadrants per visit, occlusal guards, and perio maintenance.

Fill it out for each new patient and when coverage changes, before the appointment. The front desk or insurance coordinator calls the carrier or checks the portal, completes the form, and saves it to the patient’s record so treatment estimates rest on verified benefits.