Dental insurance verification form

A free printable dental insurance verification form: every benefit to record before the visit, from coverage and maximums to frequency limits and clauses.

Updated November 11, 2026

How to use it

Print one per patient, or copy it into your practice software's notes. Fill it in from the insurer's portal or a call before the first visit, and again when the plan year renews.

Keep it with the patient's chart, not on a shared desk. It holds the member ID and date of birth.

The template

Fill in the [brackets] in your own copy. This page has no fields: nothing you'd fill in is typed here.

Patient and plan

Patient name: ________ Date of birth: ________

Subscriber name: ________ Subscriber date of birth: ________

Relationship to subscriber: ________

Insurer: ________ Phone: ________

Member ID: ________ Group number: ________

Employer: ________

Coverage start date: ________ Plan year renews: ________

In network with us? Yes / No

Other dental coverage? Yes / No If yes, which plan pays first: ________

Coverage by service

Preventive (exams, cleanings, X-rays): ____ %

Basic (fillings, extractions): ____ %

Root canals: ____ % (basic or major? ____)

Gum treatment (deep cleaning, maintenance): ____ % (basic or major? ____)

Major (crowns, bridges, dentures): ____ %

Implants covered? Yes / No ____ %

Orthodontics covered? Yes / No ____ % Lifetime maximum: $____ Age limit: ____

Deductible and maximum

Deductible: $____ per person / $____ per family Left this year: $____

Applies to preventive? Yes / No

Yearly maximum: $____ Used so far: $____ Left: $____

Waiting periods

Basic: ____ months Major: ____ months Waived? Yes / No

Frequency limits and last dates

Exams: ____ per ____ Last: ________

Cleanings: ____ per ____ Last: ________

Bitewing X-rays: ____ per ____ Last: ________

Full-mouth or panoramic X-ray: once every ____ years Last: ________

Fluoride: ____ per ____, up to age ____ Last: ________

Sealants: up to age ____, on which teeth: ________

Deep cleaning: per quadrant once every ____ years Last: ________

Perio maintenance: ____ per year, shared with cleanings? Yes / No

Crowns and bridges replaced once every ____ years

Clauses

Missing tooth clause? Yes / No

Alternate benefit for tooth-colored fillings on back teeth? Yes / No

Buildups paid with crowns? Yes / No

Pre-treatment estimate needed over $____? Yes / No

Call record

Verified by: ________ Date: ________

Portal or phone: ________ Insurer rep's name: ________ Call reference: ________

A starting point, not legal advice. Check it against your state's rules and your network contracts.

Sources

Read November 11, 2026. Where a source describes one insurer's plans, we say so.

Get the patient's share in dollars, from the benefits page

Tabruns fills in the coverage, maximum, deductible and limits from the portal for you. Tabruns reads the coverage, deductible, yearly maximum, waiting periods and frequency limits from the insurer's portal and works out what the patient owes. Patient details stay on the office computer.

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Not ready? Try the free patient portion calculator.

Dental insurance verification form

How to use it

The template

Sources

Get the patient's share in dollars, from the benefits page

Other templates