Dental Insurance Verification Form

Information you will need

• What’s the patient’s name?
• What's the name of the insurance company?
• What’s the subscriber's name?
• What’s the subscriber's date of birth?
• What's the patient’s date of birth?
• What's the patient’s SSN?
• What’s the patient’s relationship to the subscriber?
• What's the subscriber’s SSN?
• What’s the subscriber ID number?
• What's the insurance company's phone number?
• What’s the name of the subscriber’s employer? (if applicable)
• What's the group number? (if applicable)
• What's the effective date of coverage?
• When does coverage renew?
• What's the yearly maximum?
• What's the deductible per family?
• What's the deductible per individual?
• Is there a waiting period for preventative coverage?
• What’s the frequency of bitewing coverage?
• What's the effective date of preventative coverage?
• When was the patient’s last FMS?
• Is the patient eligible for an FMS?
• What’s the frequency of prophylaxis/exam coverage?
• Is there an age limit for fluoride coverage?

…and 60 more fields in the PDF.

The form includes 1 signature line.