Dental Insurance Verification Form
FULL BREAKDOWN and ELIGIBILITY CHECK form
Evolution Dental Billing compiled all the most important insurance verification questions into this one all inclusive and easy to follow form.
We need full dental benefit breakdowns for all insurance plans, annually. Complete the entire form for a full breakdown.
When the patient returns, we need an eligibility check to verify their coverage. Complete the BOLDED portions only for a patient eligibility check.
Use the empty lines to add your office specific, commonly completed procedure codes such as D6050 or D4270.
Use the space at the bottom for a copy of the patient ID and insurance cards, as needed.