INSURANCE VERIFICATION FORM

Geraldine Devine
Insured’s Name: ______________________________________ 09/29/1954
Insured’s DOB: ______________________________ 986650256
Insured SSN: ____________________________
986650256
Member ID: ___________________________________________ Geraldine Devine
Patient Name: _______________________________ 09/29/1954
Patient DOB: ____________________________
WEB
CSR Name: ____________________________________________ Dr. Todd Klein
Provider Name: _____________________________ KLEIN DENTAL ARTS
Office Name: ____________________________
H5253
Employer Name: _________________ Group Number: _________________ 1500990 United HealthCare Dental 8778163596
Insurance Name:__________________Contact Number: _______________
UNITED HEALTH CARE DENTAL CLAIMS PO BOX 30567 SALT LAKE CITY, UT 84130-0567
Insurance Address: _________________________ 521337971
Payer ID#: ______________________
NORMAL
Continued/Re-Call/New Patient:_______
01/22/2024
Appointment Date: ______________________

PPO
Plan Type: _______________ 12/31/2024 Network: _______________
Termed Date: ________________ IN NA IN WEB Coverage: ______________
Fee Schedule: _______________ FAMILY
01/01/2023
Effective Date: ___________ NA IN WEB Calendar Year(CY)/FIscal Year(FY): ________________________
Dependents covered to age? ____________________ CY
NA
Individual deductible: _______________ NA
(Met)Family deductible: ______________ 2500/00 (Used)
(Met)Annual Max: ____________
NC NC NC NC
Ortho Age Limit: ___________
Ortho Max& %: _____________ Amount used: _______________ Payment schedule: _____________________
.

100
Preventive: ___________% NO
Subject to ded? __________ 100
Diagnostic (DX-Rays): __________% NO
Subject to ded? __________
100/2X1CY
D0150______________ 100/8X1CY
D0220 __________________
100/2X1CY
D0120________________ 100/8X1CY
D0230 _______________
100/2X1CY
D0140_________________ 100/1X3CY
PANO(D0330)/FMX(D0210): ______________________________
100/2X1CY
D0145 _______________ 100/1X1CY
D0431 _________________
100/2X1CY
Prophy(D1110)___________ 13 AND ABOVE
Age ________________________ 100/1X1CY
BWS(D0274) __________________
100 2X1CY NA
Fluoride (D1208) _______________ Frequency: _____________ Age limit: _______
100/1X36MO
Sealants(D1351):___________ NA IN WEB
%Primary ____________ NA IN WEB
Premolars: ____________Perm NA IN WEB
molars: ________________ NAL
Age limit: ______________________
100
SSC (D2930): ______________________ NAL
Age limit: _______________________Frequency: 1X60MO
_____________

100
Basic: ___________% NO
Waiting Period: _________ YES
Subject to ded? _________ 100
Endo: ________% 100
Perio: _______________%
100
Gingivitis Treatment (D4346) ______________ 2X1CY
Frequency _____________________
100
Scaling & Root Planing (D4341)_____________% 1X24MO
Freq: ___________________ 02
Quads per day : ______
100/1X36MO
Night guards (D9945)__________%
100
Perio Maintenance(D4910) _______% 4X1CY
Freq: __________Alt NO
w/prophy (D1110): _____________
100
FMD (D4355) _______% 1X36MO
Freq _____________________Crown lengthening (D4249) ______ %
NA IN WEB

100/1X6MO
NO
Posterior composites (D2391) _________% Downgraded to amalgam (D2140): _____________(Yes/No)
100/1XLT
Oral surgery (D7210-7241) _________%
100/2X1CY
IV Sedation (D9248) __________% 100/NF
IV Sedation (D9243): ___________________% 100/4X1CY
Nitrous (D9230): ________________________%

100
Major: _________% NO
Waiting Period: ____________ YES
Subject to ded? ___________ NA IN WEB
Missing tooth clause? __________________
100/1X60MO
Replacement clause for prosthetics? __________________________ NA IN WEB
yrs Pays on prep or seat date? ______________________
100
Are build-ups(D2950) covered? ____________ NA IN WEB
% same day w/ crowns? _____________Freq: 1X60MO
__________
NA IN WEB
Radio/Surgical Implant (D6190) ___________________________ NC
Custom Abutment (D6057) _________________________
NC
Surgical place of implant body (D6010) __________________________________ Implant supported porc/ceramic (D6065)
________________________
NA IN WEB

100/1XLT
Bone grafts covered w/EXTs? (D7953) ________________% 100/1X60MO
100/1X60MO D2740__________________
D2750 ______________
D0120-07/13/2023, D1110-07/13/2023, D0220- 01/11/2023, D0274- 01/11/2023, D2740- 02/08/2023, D2950-02/08/2023
Complete 5YR History ____________________________________________________________________________________________________________________________
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_____________________________________________________________________________________________________________________________________________________
SAHIL SHAH
Benefits verified by: _______________________________________ 01/25/2024
Date:___________________________
Abbreviations: Benefit Year: BY, Fiscal Year: FY, Calendar Year: CY, No History: NH, Not Applicable: NA, Not Covered: NC, History:HX,
Not Provided: NP, Deductible: Ded, Not Eligible: NE, Consecutive Month: COMO
Address: Capline Dental Services - 3838 N Sam Houston Pkwy E., Suite 430 Houston, TX. 77032