§ 1 Patient, Plan & Estimate Record

Patient name Optional

Carrier and plan Optional

Benefit period Required

Estimate date Optional

§ 2 Deductible and Annual Maximum

2.1 The annual deductible, less the amount already satisfied this benefit period, is applied to covered lines in schedule order.

Annual deductible Required

Deductible already satisfied Required

2.2 The annual maximum, less benefits already paid this period, caps every plan benefit on this estimate.

Annual maximum Required

Benefits already used Required

§ 3 Itemized Dental Procedure Schedule

3.1 Coverage percentages by class, as printed on the benefit sheet. A class is required once a line uses it.

Preventive coverage Required if used

Basic coverage Required if used

Major coverage Required if used

3.2 Procedure lines are applied in the order listed. Enter the carrier’s allowed amount where known; otherwise enter the office fee.

Up to 12 lines per estimate.

STEP 2 · YOUR ESTIMATE RECORD

§ 4 Benefit Calculation and “Show the math”

Patient: Not entered
Carrier and plan: Not entered
Estimate date: Not entered

No benefit conflicts on this schedule.

Schedule of benefit determination, in the order applied
Line	Procedure	Allowed charge	Deductible	After deductible	Coverage	Plan benefit	Patient portion
Totals		Pending	Pending	Pending	Pending	Pending	Pending

Show the math

Each line runs in this order: subtract the remaining deductible, apply the coverage percentage, cap the result at the annual maximum still available, and assign the balance to the patient. Whatever deductible and maximum a line uses is no longer available to the lines after it.

§ 5 Estimated Plan Benefit and Patient Portion

Determination

ESTIMATE READY

Estimate only · Not a guarantee of payment

Deductible ledger
Deductible for the period	Pending
Remaining before this estimate	Pending
Applied by this estimate	Pending
Remaining after this estimate	Pending

Annual maximum ledger
Maximum for the period	Pending
Available before this estimate	Pending
Consumed by this estimate	Pending
Remaining after this estimate	Pending

Assumptions and carrier limitations

Amounts entered as allowed charges are treated as the carrier’s allowed amount. If you entered office fees, the plan may allow less and the patient portion may change.
The deductible is applied only to lines marked “Deductible applies”, in schedule order, and never exceeds a line’s charge.
Coverage percentages are taken from the benefit sheet as entered and rounded to the cent, half-up.
Not reflected: eligibility on the date of service, exclusions, frequency limits, waiting periods, alternate-benefit downgrades, missing-tooth clauses, and coordination with a second plan.

§ 6 Attestation, Disclaimer & Proof of Service

6.1 This is an estimate, not a guarantee of insurance payment.

Prepared by Optional

6.2 Attestation: the preparer computed this estimate from the plan terms recorded in § 1 to § 3.

Preparer signature and date

Patient acknowledgment and date

6.3 Proof of service: a copy of this workpaper was given to the patient in person, by mail, or electronically on the date signed above.

Prepared with Dental Insurance Estimate Desk

Capability	Free	Pro
Deductible, maximum, and coverage calculation	Included	Included
CSV export of the full workpaper	Included	Included
Printed workpaper	Draft with watermark	Office copy without watermark
Practice letterhead on printouts	Not included	Your name, address, and logo
Saved practice identity and preparer	Not included	Included