Dental Insurance Verification Sheet
Patient Information
Patient Name
Date of Birth
Patient ID / Chart #
Phone Number
Insurance Information
Insurance Company
Insurance Phone Number
Policy Holder's Name
Policy Holder's Date of Birth
Policy / Member ID
Group Number
Eligibility & Coverage
Effective Date
Plan Type
Annual Maximum
Deductible (Individual / Family)
Amount Met YTD
Coverage % Preventive
Coverage % Basic
Coverage % Major
Waiting Periods
Frequency Limitations
Limitations & Exclusions
Missing Tooth Clause
Replacement Periods
Excluded Procedures
Other Limitations
Coordination of Benefits
Is There Dual Coverage?
Notes
Verification Details
Spoken With
Date & Time