Dental Insurance Verification Form - Kansas

INSURANCE VERIFICATION FORM
Justin R. Dillner, D.D.S.
Patient Name: Social Security Number:
Birthdate: Relationship to Subscriber:
PATIENT INFORMATION
Subscriber Name: Social Security Number:
Birthdate: Subscriber ID Number:
SUBSCRIBER INFORMATION
Insurance Company:
Address: Phone Number:
Employer: Group Number:
Effective Date: Renewal Month: Yearly Maximum $
Deductible Per Individual $ Deductible Per Family $ This deductible applies to: Preventative Basic Major
INSURANCE INFORMATION
Does the patient have any history of SRP (D4341/D4342)? Yes No If yes, when?
Is SRP (D4341/D4342) covered? Yes No Frequency:
Can SRP (D4341/D4342) be performed on all quadrants at the same visit? Yes No
If not, what is the waiting period?
Can an adult prophylaxis and isolated SRP (D4342) be done at the same visit? Yes No
If not, what is the waiting period?
Is periodontal maintenance (D4910) covered? Yes No Frequency:
PERIODONTAL COVERAGE
Covered at % Is there a waiting period for basic coverage? Yes No Effective Date:
Includes:
BASIC COVERAGE
Covered at % Is there a waiting period for major coverage? Yes No Effective Date:
Includes:
MAJOR COVERAGE
Covered at % Is there a waiting period for preventative coverage? Yes No Effective Date:
Prophylaxis/Exam Frequency: Bitewing Frequency:
Eligible for an FMS every: years Last FMS: Eligible for an FMS now? Yes No
Flouride Varnish (D1203/D1204/D1206) Frequency:
Is there an age limit on flouride varnish applications? Yes No If yes, at age:
Is there sealant (D1351) coverage? Yes No Teeth covered: Molars Premolars
Is there an age limit on sealants? Yes No If yes, at age:
Replacement on sealants is:
PREVENTATIVE COVERAGE
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