Insurance Verification Checklist (US)

Date verified:   By:   Appointment date:  
Method: [ ] Payer portal [ ] Phone (rep name:   ref #:  ) [ ] Other

Patient and subscriber

• Patient name:   DOB:  
• Subscriber name:   Subscriber DOB:   Relationship:  
• Insurance company:   Phone:  
• Member / subscriber ID:   Group #:  
• Claims address or payer ID:  

Plan status

• Coverage active Effective date:   Termination date:  
• Is our office in network? [ ] Yes [ ] No [ ] Unsure
• Coordination of benefits (other plan)? [ ] No [ ] Yes:  

Benefits (write exactly what the payer states)

• Calendar year or plan year?   Resets on:  
• Annual maximum:   Used so far:   Remaining:  
• Deductible:   Met so far:   Applies to:  
• Coverage percentages stated by the payer: Preventive   Basic   Major   Other  
• Waiting periods:  
• Frequency limits stated by the payer (for example, how often a service is covered):  
• Missing tooth clause or other limits mentioned:  
• Pre-authorization needed? [ ] No [ ] Yes for:  

Wrap-up

• Notes saved in the patient record
• Patient told these are estimates from the payer and are not a guarantee of payment
• Estimated patient portion shared:  

Notes:  

Canada note

Many Canadian offices check coverage through the insurer, the plan administrator or the patient's benefits booklet, and some bill the insurer directly while others have the patient claim. Check which method your office uses and what each plan states. The details above (maximums, percentages, limits) are still worth recording.

Follow HIPAA (US) / your provincial privacy law (Canada) and your office policy for patient and insurance information. This sheet is administrative only and is not legal or financial advice.