Eligibility verification form

Dental eligibility verification form

Use this narrower form when the office only needs active or inactive coverage for a specific date of service, plan identifiers, verification method, and evidence source. Use the full verification form when benefits money or procedure-level rules are needed before an estimate.

Open full verification form Open checklist

Active coverage record

Patient name Patient date of birth Subscriber name Subscriber date of birth Relationship to subscriber Employer or plan sponsor Insurance carrier Plan name Member ID Group number Dental benefit plan payer ID Date of service verified Active / inactive status Effective date Termination date if shown Plan type and network status Verification method: portal, clearinghouse, or phone Representative name or operator ID Call reference number Portal screenshot or evidence file name Verification date and time

Patient intake checks before eligibility

Has your dental coverage changed since your last visit?

If yes, copy the new card or digital card and record the carrier, plan name, group number, member ID, and payer ID when available.

Have you or the policyholder had a recent employment or status change?

Listen for job loss, employer change, part-time shift, furlough, leave of absence, COBRA, or retirement language that could affect eligibility.

Did the employer or plan send paperwork about how long coverage remains active?

Ask for a copy when the patient has it, then keep the document reference with the verification note and estimate caveat.