Patient Information
- Full Name: ________________
- Date of Birth: ____________
- Insurance ID: _____________
- Group Number: ____________
Primary Insurance Details
- Insurance Company Name: ________________
- Claims Address: _______________________
- Phone Number: ________________________
- Policy Holder Name: ___________________
- Relationship to Patient: ________________
Coverage Verification
Periodontal Benefits
- Annual Maximum: $__________
- Remaining Benefits: $__________
- Deductible: $__________
- Deductible Met: ☐ Yes ☐ No
Covered Procedures
- Periodontal Scaling & Root Planing (D4341/D4342): _____%
- Periodontal Maintenance (D4910): _____%
- Full Mouth Debridement (D4355): _____%
- Osseous Surgery (D4260/D4261): _____%
- Soft Tissue Grafts (D4270/D4277): _____%
Frequency Limitations
- Periodontal Maintenance Frequency: ____________
- Scaling & Root Planing History: ____________
- Last Full Mouth X-rays: ____________
Authorization
- Pre-authorization Required: ☐ Yes ☐ No
- Waiting Period: ☐ Yes ☐ No
- If yes, expires: ____________
Verification Details
- Date Verified: ____________
- Staff Member: ____________
- Reference Number: ____________
Note: Benefits quoted are not a guarantee of payment. Final coverage determination will be made when the claim is processed.