BENEFIT BREAKDOWN QUESTIONNAIRE

This Financial Coordinator resource document can be used to help you manage insurance benefits for each patient by breaking down their benefits. You can use this form to capture patient information, coverage percentages, frequency, and hygiene. There is also a place to enter your fees versus UCR and ortho if needed.

BENEFIT BREAKDOWN QUESTIONNAIRE

PATIENT INFORMATION

PATIENT NAME: ___________________ DOB: ______________________
SUBSCRIBER NAME: _________________ DOB: ____________________
SUBSCRIBER ID OR SSN: ___________ EMPLOYER: ________________

INSURANCE INFORMATION AND COVERAGE PERCENTAGES

INSURANCE NAME: __________________ GROUP #: ________

ANNUAL MAX: $ ______ CIRCLE ONE: CAL. YR. / BENEFIT YR.  ANNUAL MAX REMAINING: $ ______________

DEDUCTIBLE: $ ______________ APPLIES TO: P / B / M FAMILY: YES NO

PREVENTATIVE PAID AT: ________ % ANNUAL MAX APPLIED TO PREVENTATIVE? YES NO

BASIC PAID AT: ___ % DEDUCTIBLE: YES NO BASIC INCLUDES: ________

MAJOR PAID AT: ___ % DEDUCTIBLE: YES NO MAJOR INCLUDES: _______

PROPHY: ______ EXAM: _______ B/W: __________

View the complete document and print out a copy for your office below!
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