Patient form

Patient Insurance Breakdown Inquiry

Use this form to organize insurance plan questions before a visit. Coverage details depend on the patient's plan and should be confirmed with the insurance provider and clinic.

Back to Forms

Plan Information

Patient name Insurance company Plan # I.D. # Subscriber name Subscriber date of birth

Covered as of Today

01202 - New Patient Exam 02144 - Panorex X-ray 02102 - Full Mouth X-rays 11101 - Scaling 11111 - Scaling units 12101 - Polishing 43421 - Root Planing 43521 - Root Planing 01103 - Recall Exam 02601 - Bitewing X-rays

General Policy Inquiry

Fee guide year Dental yearly maximum Routine treatment percentage Major treatment percentage Composite filling coverage on molars Composite example notes

Dental Claims Submission

E.D.I. submission accepted? Assignment of benefits to dentist accepted? Covered notes Not covered notes

Online submissions are encrypted and stored in the private Admin inbox. The office receives an email notification without insurance answers. Coverage still requires confirmation with the insurer.