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Insurance Verification Form
Electronic Benefits Summary · CDT 2026
Verified by
Date of Call
Carrier Name
Insurance Phone
Call Ref #
1
Plan & Carrier Info
Group Plan Name
Group #
Payor ID
Effective Date
Benefit Type
Select…
Calendar Year
Fiscal Year
Contract Year
Policy Year
Other
Specify Benefit Type
Details
Network Status
In-Network (PPO)
Out-of-Network
HMO / DMO
Claims Address
⚠ Out-of-Network Details
OON Coverage?
Select…
Yes
No
2
Subscriber & Patient
Subscriber Name
Subscriber DOB
Sub ID / SSN
Patient Name
Patient DOB
Relationship
Select…
Self
Spouse
Child
Other
3
Benefits & Maximums
Annual Max
$
Max Remaining
$
Indiv. Ded.
$
Indiv. Ded. Rem.
$
Family Ded.
$
Family Ded. Rem.
$
4
Coverage Percentages
Preventive %
Basic %
Major %
Ortho?
Yes
No
Ortho Benefits
Ortho %
Lifetime Max?
Yes
No
Ded. Applies?
Yes
No
Annual Max
$
Remaining
$
Ded. Amount
$
Ded. Remaining
$
Child Age Limit
Emplo. Age Limit
Endo
Category…
Basic
Major
Preventive
Not Covered
Perio
Category…
Basic
Major
Preventive
Not Covered
Simple Ext.
Category…
Basic
Major
Not Covered
Surgical Ext.
Category…
Basic
Major
Not Covered
Ded. Category
Preventive
Basic
Major
Diag App. Max
Yes
No
Waiting Period?
Yes
No
⚠ Waiting Period Details
Preventive
MONTHS
Basic
MONTHS
Major
MONTHS
Ortho
MONTHS
★
Appt Codes
CDT Code
Description
Benefit %
Frequency
Ded Applies?
Age Limit
Add Code
Add Appt Codes
5
Common Procedures · CDT 2026
CDT Code
Description
Benefit %
Frequency
Ded Applies?
Age Limit
Add Procedure Row
6
Policy Rules
Are posterior composites downgraded?
Yes
No
Notes
Does the carrier pay on the prep date or the seat date?
Prep Date
Seat Date
Notes
Can all 4 quads be done on the same day?
2
4
Notes
Can quads be done on the same day as prophy?
Yes
No
Notes
Periodontal shares frequency with prophy?
Yes
No
D4346?
Yes
No
D4355?
Yes
No
D4910?
Yes
No
Notes
Missing Tooth Clause?
Yes
No
Notes
Perio maintenance — same day as exam?
Yes
No
Notes
Implant coverage — any exclusions?
Yes
No
Notes
Occ. Guards covered?
Yes
No
For bruxism only?
Yes
No
Notes
Is there any regulation for anesthesia to be covered?
Yes
No
Notes
✎
General Notes
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