Patient Name:_______________________ DOB:__________________ ID: _____________________

Subscriber Name: _______________________ Relationship to subscriber: _________________

Insurance Name: ___________________Group #: ________________ Phone #: ______________

Fax #: ___________________ Date of Phone Pre-auth: _______________Pre-auth #: _________

Contact Person: ________________ Ext: __________ Time of Conversation: ________________

Treatment Needed

Diagnosis (ICD-9)                                       Procedure (CPT Codes)

1.____________________                                1.________________________

2.____________________                                2. ________________________

3. ___________________                                 3. ________________________

4. ___________________                                 4. ________________________

Coverage Information

Out-Of Network Benefits? _____________Covered Benefit? Yes ___ No _____

Deductible: ___________ Deductible used/remaining: ___________

Are there any special qualifications or restrictions for these procedures?

_____Covered only if traumatic injury     _____ Covered only if performed by specialist

_____ In-Network benefits only               _____ Other Restrictions

Are our fees within your fee limitations? __ yes __ no

Maximum Allowable fee: ___________

Our Policy Regarding Medical Claims

We are happy to file medical claims for patients requiring medical-related dental services.  As a special courtesy, we have taken the time to contact your medical plan to obtain your coverage information.  However, we cannot accept responsibility for the accuracy of the information provided by your medical carrier.  A copy of this phone preauthorization is being given to you so you have the necessary information to follow up on your medical claims if the estimated reimbursement is not received.

Prepared by: __________________________________

 Date Prepared: ________________________________

Christine Taxin
36 Abington Avenue
Ardsley, New York 10502
United States of America