INSURANCE INFORMATION

Billing Provider: _______________________________________________________________ Tax ID: ____________________________________________________________

How Retrieve/Representative’s Name: ___________________________________________________ Date: _______________ Initial: ________________________________________
Patient’s Name: __________________________________________________________________ Patient’s BOD: ______________________________________________________
Relationship to the Subscriber: _________________________________________________________ Effective Date: ____________________________ Ref#: _____________________
Subscriber Name: ____________________________________________________________________ BOD: ____________________________ SS# : _______________
Subscriber ID No: ______________________________________________________________________Group Name: ___________________ Group No: ________________________
Insurance Carrier: _____________________________________________________________________ Payor ID No: ______________________________
Mailing Address: _______________________________________________________________________ Insurance Phone No: ___________________________________

PLANE COVERAGE

Plan Covers: ___________________________________________________ Other: ________________________________ Contracted? ☐In Network ☐Out of Network
Benefit Paid on: ☐UCR ☐Contracted Fee ☐Allowable Fees ☐Fee Schedule: If Delta: ☐Premier ☐PPO
☐Calendar Year ☐Fiscal Year: _________ to ___________
Maximum: $_______ D/P Waived? ☐Y ☐N Remaining: $_______ Claims Pending? ☐Y ☐N
Basic: _______ Major: __________
DEDUCTIBLE: Individual $_______ Family $_______ Deductible Satisfied? ☐Y ☐N Waived on Preventive? ☐Y ☐N
Pre-Authorization Required? ☐Y ☐N Suggested Amount? $_______ (N/A If no Pre- Auth Sugg) D/p = Diagnostic/Preventative
Claim Deadline: __________ Coordination Of Benefits: ☐Standard ☐Non-Coordination ☐Non Duplicate R= Restoration, E=Endo
Age Limit of Dependents: ______ FT Student: _____ P= Perio, OS= Oral Surgery
Preventive: _____% Includes: ☐Exams ☐X-Rays ☐Prophylaxis ☐Perio Maint ☐Flouride Sealants CR= Crown, BU= Buildup
(Additional Procedure): ____________________________________ I= Implant, PR=Prosthodontics
Basic: _____% Includes: ☐Endo ☐Perio ☐Oral Surgery ☐Single Crowns NG= Night Guard , O = Ortho
(Additional Procedure): ____________________________________ FMD = Full Mouth Debridement
Major: _____% Includes: ☐Endo ☐Perio ☐Oral Surgery ☐Crowns/Bridges ☐Implants ☐Prosthodontics
(Additional Procedure): ____________________________________

FREQUENCY
FMX 0210 PANO 0330 BWX 0274 EXAM 0120 PROPHY 1110
1 x☐3yrs/36m ☐5yrs/60m 1 x☐3yrs/36m ☐5yrs/60m ☐1 ☐2 x ☐6m ☐12m ☐ ☐1x 6m ☐2x1 Year Limited 0140- ☐1 x6m ☐2x1 year
______________ 24m ______________
PA 0220/0230- Shared Freq w/LMTD Exam Shared Freq W/Perio Maint
Shared Freq w/Pano ______________ ______________ ☐YES ☐NO
☐YES ☐NO ______________ ______________ ☐YES ☐NO

FLURIDE 1206/1208 PERIO MAINT (4910) SRP’S 4341/4342 FILLINGS 2393 CROWNS 2740
☐2x 1yr ☐1x 6m ☐NC ☐2x 1yr ☐1 x 6m ☐4 x 1yr 1 x☐24m ☐36m 1 x☐24 ☐36m ☐12m Poster Comps? 1 x ☐5yrs ☐7yrs ☐10yrs
☐______________ ☐____________ ☐no Fre ☐ X-ray ☐NF ☐______________
Up to Age: _______ ☐Perio Chart ☐YES ☐NO ☐Pay on Seat
☐No Age Limit _______Quads in 1 Visit On Pre-Molars? ☐Prep Date Procelain on Post Tth?
Wait ______ Days Post Perio ☐YES ☐NO ☐YES ☐NO
Arestin 4381 _________ Comps Downgraded to Amalgam? Crowns Downgraded to Metal?
______________ ☐NC ☐YES ☐NO ☐YES ☐NO
______________ ☐NF 2740
 _________

BRIDGES 6245 DENTURES 5110 FLURIDE 1206/1208 FLURIDE 1206/1208 FLURIDE 1206/1208
1x ☐5yrs ☐7yrs ☐10 yrs 1 x ☐5yrs ☐7yrs ☐10yrs 1 x ☐5yrs ☐7yrs ☐10yrs ☐1 x_________months ☐ 1 x LT
Prior Exts Covered? ☐NC ☐NC ☐LT ☐NF ☐NC ☐ Takes Place of Prophy
☐YES ☐NO ☐6057 ☐Brux Only ☐ _________________
Missing Tooth Exclusion? ☐6058 ☐By Report
☐YES ☐NO ☐6 months
Alt Benefit?
HISTORY PROFILE
ORTHO CROWNS
FMX 0210 PANO 0330 BWX 0274 EXAM 0120 PROPHY 1110 PERIO 4910 SRP’S 4341/4342 NG
8080/8090 2740/2790
__________ __________ __________ __________ __________ __________ __________ __________ __________ __________
__________ __________ __________ __________ __________ __________ __________ __________ __________ __________
__________ __________ __________ __________ __________ __________ __________ __________ __________ __________
ADDITIONAL CODES
Sealants 1351 ☐Y ☐N ____% Up to age: 1st: _____ 2nd :_____ Freq:_____ Orthodontics 8080 ☐YES ☐NO _____%
Pallative 9110 ☐Y ☐N ____% Orthodontics 8090 ☐YES ☐NO _____%
Build Up 2950 ☐Y ☐N ____% Same day as crown: ☐Y ☐N Freq:_____ Orthodontics Ded ☐YES ☐NO $ __________
Nitrous 9230 ☐Y ☐N ____% D9310 Consultation:_____________ Ortho Pay Freq ☐Monthly ☐Quarterly ☐Semi Annual ☐Annual
OCS 0431 ☐Y ☐N ____% Oral Surg 7240: medical EOB Req? ☐Y ☐N Auto Pay ☐YES ☐NO
Gum Graft 4275 ☐Y ☐N ____% Covers Work In Progress ☐YES ☐NO
Osseous 4260 ☐Y ☐N ____% SRP 1st ☐Y ☐N_____% Used in conjunction with 4273 _______ Ortho Max:____________ Rem Max: ______________
Simple Ext 7110 ☐Y ☐N ____% Porcelain Alt Benefit?____________ Life Time: ☐YES ☐NO Age Limit Dep: _________ Adult: ________
Sung Ext 7210 ☐Y ☐N ____% Porcelain Alt Benefit?____________
Full Bony 7240 ☐Y ☐N ____%
Note: