FOR OFFICE USE ONLY
Date verified_____________ Verified by____________________
PRIMARY
In network:
LTM ____________
pays at _______%
Deductible ________
Wait________
Out of network:
LTM ____________
pays at _______%
Deductible ________
Wait________
Age Limit _____________/_____________
How are benefits paid out: Auto or Bill
Monthly, Quarterly, Semi-Annual, Annual, Other
Have any benefits been used: Y/ N
How much________________
Have any benefits been used: Y/ N How much________________
Balance left ____________
Coordination of Benefits:____________________
Pre-Existing/Will treatment in progress be pro-rated: Y N
Coverage for space maintainer?_____________
Confirm Ins. address: PO. Box__________________________________
____________State_____________________Zip code:_____________
Grp#_________________________ ID#______________________
Phone#_____________________