Insurance Verification Form

Instructions: Prior to your appointment, please call your insurance company, print and complete this form in its entirety and fax or e-mail back to us.

Patient Insurance Verification Form

* Patient Name: (Required)

Date of Birth:

Primary Insurance

Insured:

Date of Birth:

SS or ID#:

Employer:

Group#:

Insurance Company:

Phone Number:

Insurance Company Address:

City:

State:

Zip:

Please Ask Your Insurance Company Representative the Following Questions

What is the effective date of my coverage?

What is the individual lifetime orthodontic maximum covered?

At what percentage is the benefit paid? (Usually 50%)

Do we have a deductible? Yes No

If yes, is it annual or Lifetime?

Amount:

Is the benefit paid to my Orthodontist automatically? Please check below: Monthly Quarterly Annually Semi-Annually

Do you pay out of network benefits?

Is there a waiting period?

Is there an age limit?

What is the age limit?

Are spouse and employee covered? Yes No

Have any benefits for Orthodontics been used?

Is there a time limit to file?

Verified by: (Name of person from insurance company you spoke with)

Name:

Date:

If this was an automated call, please initial:

Date:

I understand that estimates benefits quoted to me and/or Dr. Gragg by my insurance company are not a guarantee of payment and that I am responsible for any and all fees not paid by my insurance company.

Signature of Insured:

Date:

Security Measure