Insurance Breakdown

Reference # *

Date *

Verified by *

Rep name *

Subscriber Name *

D.O.B *

ID/SSN# *

Patient Name *

D.O.B *

Insurance Info: Insurance Company *

Phone # *

Group # *

Employer *

Effective Date *

Max $*

Remaining Max $ *

Plan Type *

Payor ID # *

Preventive %*

Basic % *

Major % *

Ind. Ded. $ *

Met *YesNo

Fam. Ded. $ *

Met *YesNo

Is Deductable waived on Preventive? *YesNo

Frequencies *AnytimeTo The DayTo The Month

Exams *

Lim. Exams (shares/addt'll/sep) *

BW *

PA's *

FMX *

Prophy (shares/addt'll/sep)*

Perio *

HX Req? *YesNo

FM Debridement(4355) *

SRP(4341) *

Can all 4 quads be done the same day? *YesNo

Age Limit *

How soon after SRP can PT and Perio or Prophy? *

Arestin(4381) *

How many teeth/quads? *

Pocket Depth *

SRP HX Req*YesNo

Fluoride/Varnish *

Age Limit *

Sealants *

Age Limit*

Nightguard(9944) *

Fills *

Covered or Downgraded *CoveredDowngraded

Nightguard(9945) *

Fills *

Covered or Downgraded *CoveredDowngraded

Replacement Limitation on PFM, BB, DENT *

Paid on *PrepSeat

Ortho Coverage *YesNo

%*

Age Limit *

Lifetime Max $*

HX *

Exams (0150,0140) *

BW*

FMX *

Prophy *

Perio *

SRP *

LR *

LL *

UL *

NG *

Fluoride *

sealants*

PFM's *

Other HX*