Dental Insurance Verification Form - Kansas
Are endosteal implants (D6012) covered? Yes No If yes, covered at %
Are bone replacement grafts (D7953) covered? Yes No If yes, covered at %
Are guided-tissue regeneration barriers (D4266/D4267) covered? Yes No If yes, covered at %
Are implant abutments (D6056/D6057) covered? Yes No If yes, covered at %
Are implant crowns (D6065/D6066/D6067) covered? Yes No If yes, covered at %
Is a pre-determination required prior to implant surgery? Yes No
IMPLANT COVERAGE
Are nightguards (D9940) covered? Yes No If yes, covered at %
Is nitrous oxide (D9230) covered? Yes No If yes, covered at %
Replacement on crowns and bridges is: years
Replacement on complete and partial dentures is: years
Are prior extractions covered (missing tooth clause)? Yes No
MISCELLANEOUS
Completed By: Date:
ADDITIONAL NOTES
Are orthodontics covered? Yes No If yes, covered at %
Is there an age limit on orthodontic coverage? Yes No If yes, at age:
Is there a lifetime maximum? Yes No If yes, the lifetime maximum is:
ORTHODONTIC COVERAGE
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