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MEMBER DENTAL CLAIM FORM HEADER INFORMATION INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION OTHER COVERAGE (Mark applicable box and complete 5-11. If none, leave blank.) RECORD OF SERVICES PROVIDED AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION TREATING DENTIST AND TREATMENT LOCATION INFORMATION 1. Type of Transaction (Mark all applicable boxes) ☐Statement of Actual Services ☐Request for Predetermination/Preauthorization ☐EPSDT / Title XIX 4. Dental? ☐ Medical? ☐ (if both, complete 5-11 for dental only.) 7. Gender ☐M ☐F 10. Patient’s Relationship to Person named in #5 ☐Self ☐Spouse ☐Dependent ☐Other 40. Is Treatment for Orthodontics? 41. Date Appliance Placed (MM/DD/CCYY) ☐No (Skip 41-42) ☐Yes (Complete 41-42) 46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State 45. Treatment Resulting from ☐Occupational illness/injury ☐Auto accident ☐Other accident 18. Relationship to Policyholder/Subscriber in #12 Above ☐Self ☐Spouse ☐Dependent Child ☐Other 19. Reserve For Future Use 5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix) 6. Date of Birth (MM/DD/CCYY) 8. Policyholder/Subscriber ID (SSN or ID#) 9. Plan/Group Number 11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code 36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim. Patient/Guardian Signature Date 37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity. Subscriber Signature Date 53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed. Signed (Treating Dentist) Date BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.) 48. Name, Address, City, State, Zip Code 56. Address, City, State, Zip Code 56a. Provider Specialty Code 49. NPI 50. License Number 51. SSN or TIN 38. Place of Treatment (e.g. 11=office; 22=O/P Hospital) 39. Enclosures (Y or N) (Use “Place of Service Codes for Professional Claims”) ☐ 52. Additional Provider ID 52a. Phone Number ( ) - 57. Phone Number 58. Additional Provider ID ( ) - 33. Missing Teeth Information (Place an on each missing tooth.) 35. Remarks 34. Diagnosis Code List Qualifier ☐☐(ICD-9 = B; ICD-10 = AB) 34a. Diagnosis Code(s) A C (Primary diagnosis in B D 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 2. Predetermination/Preauthorization Number 3. Company/Plan Name, Address, City, State, Zip Code POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in PATIENT INFORMATION 12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code 20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code 14. Gender ☐M ☐F 17. Employer Name 13. Date of Birth (MM/DD/CCYY) 15. Policyholder/Subscriber ID (SSN or ID#) 22. Gender ☐M ☐F 31a. Other Fee(s) 32. Total Fee 21. Date of Birth (MM/DD/CCYY) 23. Patient ID/Account # (Assigned by Dentist) 16. Plan/Group Number 54. NPI 55. License Number 42. Months of Treatment 43. Replacement of Prosthesis 44. Date of Prior Placement (MM/DD/CCYY) Remaining: ☐No ☐Yes (Complete 44) 1 2 3 4 5 24. Procedure Date (MM/DD/CCYY) 27. Tooth Number(s) or Letter(s) 28. Tooth Surface 29. Procedure Code 29a. Diag. Pointer 29b. Qty. 30. Description 31. Fee 25. Area of Oral Cavity 26. Tooth System 5730 (4-13) Please submit claim to: Dental Claims P.O. Box 69406 Harrisburg, PA 17106-9406 Please submit claim to: Dental Claims P.O. Box 69406 Harrisburg, PA 17106-9406