pinnaclepeakorthodontics - Insurance Verification Form

INSURANCE VERIFICATION FORM

In order to assist you in verifying your orthodontic insurance benefit, the following information
MUST BE FILLED OUT COMPLETELY:
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name of Person Who Carries the Insurance
Date of birth

MonthDayYear
Date
Social Security #
ID#
Phone Number
Please enter a valid phone number.
Employed By
Business Phone #
Please enter a valid phone number.
Address
Insurance Company
Policy/Group #
Address of Insurance Company

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ins Company Ph#
Please enter a valid phone number.
If patient is covered under another Dental Plan, please complete another insurance form.

I hereby authorize release of any information relating to this claim and authorize payment directly to the named orthodontist of the insurance benefits.
Signature

Clear
Date

MonthDayYear
Date
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#_____________________
Should be Empty:

INSURANCE VERIFICATION FORM