Dental Insurance Pre-Authorization Request Form
Patient Information
Patient Name
Date of Birth
Patient ID / Member #
Address
City
State
ZIP
Phone
Email
Insurance Information
Insurance Company
Group Number
Policy Number
Plan Type
Subscriber Name
Subscriber DOB
Provider Information
Provider Name
NPI #
Office Phone
Office Fax
Office Address
City
State
ZIP
Request Details
Procedure Code(s)
Proposed Date of Service
Description of Services
Rationale/Medical Necessity
Signature
Provider Signature
Date