Claim Form

Dentist Name:
Phone:

Email:
NPI:
TIN:
ProviderID:

Name:
DOB:

Group Number:
Member ID:
Member Key:

If any additional/supplemental insurance was used to pay for any of this claim, add that information here.

Does the patient have additional insurance that applies to this claim?

Yes

No

What type of insurance is this?

Dental

Medical

If the patient has an EOB (Explanation of Benefits) for this dental/medical visit, it will need to be added to this claim. Instructions on how to add the EOB are in the final section of this form.

Subscribers first name

Subscribers last name

Subscribers middle initial

Subscribers date of birth

Insurance company name

Patients Relationship to subscriber

Please enter a billed amount for items below.

Service Date

Procedure	Decscription	Unit	Tooth Number	Billed Amount	Exception Code

Edit Treatment Plan

Does this claim include orthodontics?

Yes

No

When was the orthodontics appliance placed?

Total number of months the patient recieved (or, is receiving) orthodontic care?

Does this claim include prosthesis (crown, bridge, denture)?

Yes

No

Is this an initial placement of prosthesis (crown, bridge, denture)?

Yes

No

Is this a replacement of prosthesis (crown, bridge, denture)?

Yes

No

When was the prior placement?

What was the reason for replacing the prothesis?

Does this claim relate to an accident, injury, or illness?

Yes

No

What type of accident, injury or illness?

Work accident or illness

Auto accident

Neither of these

When did the accident or injury occur?

Missing Teeth
Seperate multiple tooth numbers with a comma (1, 7, 16)

Other Remarks
Please include any non-dental procedure diagnosis codes, digital attachment ID's, provider narrative, office discounts applied or other comments.

250 characters remaining

To ensure timely processing of this claim, please upload documents associated with the patient's procedure(s).

You may need the patients:

Peridontal Chart(s) or X-rays
Charting notes
Billing Statement
Explanation of Benefits (EOB) from additional insurance, if applicable

Select the button below to upload documents to this claim

Documents remaining:: 20/20
Upload space remaining:: 20MB/20MB
Accepted file formats:: .pdf, .png, .jpg, .txt, .rtf, .tif, .bmp, .tiff

Fraud Notice

Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Acknowledgements and Signature

I certify that the procedures indicated on this form are either in progress or have been completed. I understand that by putting my name in the field below, I am signing this form electronically.

Provider Acknowledgement

The dentist or dental office has explained the dental treatment plan and costs to the patient or authorized representative. The office costs to the patient or authorized representative. The office has a patient or authorized representative signature stating that the patient or authorized representative will be responsible for all charges for dental services and materials not paid by the patient's dental benefit plan, unless the charges are not allowed by law. The patient or authorized representative has also agreed in writing that the dentist or dental office can use and disclose the patient's protected health information in order to process this claim.

Provider Acknowledgement

The dentist or dental office has a signature on file of the patient or authorized representative allowing direct payment to the dentist or dental office.

Provider Signature

Today's Date

Provider Information

Patient Information

Additional Insurance

Procedure

Additional Claim Information

Upload Documents

Fraud Notice

Acknowledgements and Signature