Nalain Muhammad

COMPLETE INSURANCE VERIFICATION FORM Updated: 08/05/2024 Arlinda Smith PATIENT NAME: _____________________________________________________________ 04/05/- DOB: _________________________SS# OR ID#: __________________________ SUBSCRIBER NAME: ________________________________________________________ DOB: _________________________SS# OR ID#: __________________________ GROUP NAME: ______________________________________________________________ GROUP #: _____________________COB RULE: ___________________________ UHC AARP INSURANCE CO: ____________________________________________________________ - PHONE: ______________________ IVF DATE: ____________________________ 557 S Marietta Pkwy SE, Marietta GA 30060 ADDRESS: _________________________________________________________________ - PAYOR ID #: ___________________REF#: ________________________________ Sunil Singh IN-NET: ✔ DENTIST NAME: _________________________________ OUT-NET: TIMELY FILING: ______________________________________________________ EFFECTIVE DATE: _______________________CAL: FISCAL: FROM: ________TO: ____________ OON BENEFITS? YES: MAX:___________________________________MAX REMAINING: ____________________ ROLLOVER: ___________________IND COV: DEDUCTIBLE: ___________________________FAMILY DED: ________________________ DED MET? YES NO NO: FAM COV: WAIVED ON PREV? YES: NO: NO: PREVENTATIVE: ________% IN-NET OUT-NET ENDO: _______________% IN-NET OUT-NET PREV APPLIES MAX? YES: BASIC: ________________% IN-NET OUT-NET PERIO: ______________ % IN-NET OUT-NET MTC: YES: NO: MAJOR: _______________% IN-NET OUT-NET O.S.: ________________ % IN-NET OUT-NET WAITING PERIOD? YES: NO: WAITING PERIOD APPLIES TO: PREV/DIAGN ________________ RESTORATIVE ___________________ WAIT. PERIOD MET? YES: PERIO ______________________ MAJOR __________________________ SEALANTS AGE LIMIT: _______________________________________________________ NO: FL TX AGE LIMIT: ____________________________________________________ BASIC CODES / RECARE PROPHY FREQUENCY: _________________ 2/12M 2/YR 1/6M LAST PROPHY: ________________ SHARE W/ D4910? YES: NO: EXAM FREQUENCY: ___________________ PER ________________________________ LAST EXAM: __________________ SHARE FREQ D0140: YES: NO: BW'S FREQUENCY: ___________________ PER ________________________________ LAST BWX: ___________________ SHARE FREQ: YES: NO: FMX FREQUENCY: ___________________ PER ________________________________ LAST FMX/PANO: ______________ SHARE FREQ: YES: NO: PA'S FREQUENCY: ___________________ PER ________________________________ PERIO D0180: _________________ PALLIATIVE: D9110 ________________ % D4910: __________% ___________________ D4355: __________%__________________ REPLACE WITH D1110? YES: D4341: __________% ___________________ NUMBER OF QUADS DONE ON THE SAME DOS: 2 QUADS COMPS FREQUENCY: ___________________________________COMPOSITE POSTERIOR: DG? YES: NO: 4 QUADS NO: NEXT QUAD: ________________ BI'S? YES: NO: RESTORATIVE CODES D2740: _________% DG POST? YES: NO: D2960: _________% D2962: ________% TO CODE: D ____________ PAID ON: PREP: SEAT: BRIDGE / PARTIALS / DENTURES: _________ % REPLACEMENT? ____________________________ SURGERY D4249: ___________% _______________ ___________% _______________________________ D7310: _____________% _____________________________ D4266/7: ___________% _______________ D7952/3: ___________% _______________________________ D7320: _____________% _____________________________ D6010: ___________% _______________ D6057: ___________% _______________________________ D9239: _____________% _____________________________ D4211/2: ___________% _______________ D6058: ___________% _______________________________ D9243: _____________% _____________________________ D9230: AGE LIMITS: __________________________________________ D9248: _____________% _____________________________ ___________% _______________ D7951: OCC GUARD D9944: _____________ % BRUXMISM? YES: NO: D8040: _________________________ % AGE LIMITS: ____________________ PERIO? YES: NO: ORTHO ORTHO MAX: __________________ORTHO USED: ________________________ ORTHO: YES: NO: WAITING PERIOD? YES: LIFETIME MAX: YES: NO: DED: $ _______________ PAYMENT SCHEDULE: ___________% REMAINING PAYMENTS: AUTO NO: WORK IN PROGRESS? YES: MANUAL NO: FREQ: MONTHLY QUARTELY ANUALLY NOTES The information in this form is sourced from the designated dental insurance. While we strive for accuracy, EZ Dental Billing LLC is not liable for any discrepancies, inaccuracies, or inconsistencies in this summary. Importantly, even dental insurance providers do not guarantee or accept responsibility for the information they supply. ______________________________ ___________________________ Responsible Agent Date