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Dental Insurance Verification Form

Walk through a dental plan's coverage, deductibles, and waiting periods step by step before treatment begins.

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Patient name

Nombre

Apellido

Date of birth

Relationship to subscriber

Name

Nombre

Apellido

Date of birth

Insurance company

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Employer

Effective date

Renewal month

This deductible applies to:

Individual Family

Percentage of coverage

Is there any waiting period for basic coverage?

Yes No

Effective Date

Describe what the coverage includes.

Percentage of Coverage

Is there a waiting period for the preventative coverage?

Yes No

Effective Date

Describe what the coverage includes.

Percentage of Coverage

Is there a waiting period for the preventative coverage?

Yes No

Effective Date

Prophylaxis/Exam frequency

Bitewing frequency

Fluoride varnish frequency

Is there an age limit on fluoride varnish applications?

Yes No

What age?

Is there sealant coverage?

Yes No

Which teeth are covered?

Is there an age limit on sealants?

Yes No

What age?

Describe replacement on sealants

Additional notes

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