MEMBER DENTAL CLAIM FORM
HEADER INFORMATION Please submit claim to:
1. Type of Transaction (Mark all applicable boxes) Dental Claims
P.O. Box 69421
☐ Statement of Actual Services ☐ Request for Predetermination/Preauthorization Harrisburg, PA 17106-9421
☐ EPSDT / Title XIX
2. Predetermination/Preauthorization Number POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3)
12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION
3. Company/Plan Name, Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY) 14. Gender 15. Policyholder/Subscriber ID (SSN or ID#)
☐M ☐ F
OTHER COVERAGE (Mark applicable box and complete 5-11. If none, leave blank.) 16. Plan/Group Number 17. Employer Name
4. Dental? ☐ Medical? ☐ (if both, complete 5-11 for dental only.)
5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix) PATIENT INFORMATION
18. Relationship to Policyholder/Subscriber in #12 Above 19. Reserve For Future Use
6. Date of Birth (MM/DD/CCYY) 7. Gender 8. Policyholder/Subscriber ID (SSN or ID#) ☐ Self ☐ Spouse ☐ Dependent Child ☐ Other
☐M ☐ F 20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
9. Plan/Group Number 10. Patient’s Relationship to Person named in #5
Self ☐ Spouse ☐ Dependent ☐ Other ☐
11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code
21. Date of Birth (MM/DD/CCYY) 22. Gender 23. Patient ID/Account # (Assigned by Dentist)
☐M ☐ F
RECORD OF SERVICES PROVIDED
25. Area 26.
24. Procedure Date 27. Tooth Number(s) 28. Tooth 29. Procedure 29a. Diag. 29b.
of Oral Tooth 30. Description 31. Fee
(MM/DD/CCYY) Cavity System or Letter(s) Surface Code Pointer Qty.
1
2
3
4
5
33. Missing Teeth Information (Place an “X” on each missing tooth.) 34. Diagnosis Code List Qualifier ☐☐ (ICD-9 = B; ICD-10 = AB) 31a. Other
Fee(s)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 34a. Diagnosis Code(s) A _______________ C ________________
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 (Primary diagnosis in “A”) B _______________ D ________________ 32. Total Fee
35. Remarks
AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all 38. Place of Treatment (e.g. 11=office; 22=O/P Hospital) 39. Enclosures (Y or N)
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 (Use “Place of Service Codes for Professional Claims”) ☐
all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure 40. Is Treatment for Orthodontics? 41. Date Appliance Placed (MM/DD/CCYY)
of my protected health information to carry out payment activities in connection with this claim.
☐ No (Skip 41-42) ☐ Yes (Complete 41-42)
42. Months of Treatment 43. Replacement of Prosthesis 44. Date of Prior Placement (MM/DD/CCYY)
X __________________________________________________________________
Patient/Guardian Signature Date
Remaining:
☐ No ☐Yes (Complete 44)
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to 45. Treatment Resulting from
the below named dentist or dental entity.
☐ Occupational illness/injury ☐ Auto accident ☐ Other accident
X __________________________________________________________________ 46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State
Subscriber Signature Date
BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not TREATING DENTIST AND TREATMENT LOCATION INFORMATION
submitting claim on behalf of the patient or insured/subscriber.) 53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require
48. Name, Address, City, State, Zip Code multiple visits) or have been completed.
X __________________________________________________________________
Signed (Treating Dentist) Date
54. NPI 55. License Number
56. Address, City, State, Zip Code 56a. Provider
49. NPI 50. License Number 51. SSN or TIN Specialty Code
52. Additional Provider ID 52a. Phone Number 57. Phone Number 58. Additional Provider ID
( ) - ( ) -
5730 (4-13)
Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information or
conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties.
CA: For your protection California law requires that the following appear on the form: Any person
who knowingly presents a false claim for the payment of a loss is guilty of a crime and may be
subject to fines and confinement in state prison.
DC & RI: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
FL: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete or misleading information
is guilty of a felony in the third degree.
IN & OK: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive an
insurer, makes any claim for the proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a felony.
KY: Any person who knowingly and with intent to defraud any insurance company or other person
files a statement of claim containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime.
LA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application for insurance is guilty of a crime and
may be subject to fines and confinement in prison.
NJ: Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
NY: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false
information, or conceals for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject
to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each
such violation.
VA: Any person who within the intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement may
have violated the state law.
TN & WA: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include imprison-
ment, fines and denial of insurance benefits.
MD: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss
or benefit or who knowingly or willfully presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
AZ: For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment of a loss is subject to
criminal and civil penalties.
Discrimination is Against the Law
The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Plan does
not exclude people or treat them differently because of race, color, national origin, age, disability, or sex
assigned at birth, gender identity or recorded gender. Furthermore, the Plan will not deny or limit
coverage to any health service based on the fact that an individual’s sex assigned at birth, gender identity,
or recorded gender is different from the one to which such health service is ordinarily available. The Plan
will not deny or limit coverage for a specific health service related to gender transition if such denial or
limitation results in discriminating against a transgender individual.
The Plan:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other
formats)
Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Plan has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity,
you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222,
Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: [email protected].
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil
Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights electronically through the Office for
Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or
phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
English ATTENTION: If you speak English, language assistance services, free of charge, are available to
you. Call 1-800-332-0366 (TTY: 711).
Español ATENCIÓN: Si habla español, le ofrecemos servicios gratuitos de asistencia lingüística.
(Spanish) Llame al 1-800-332-0366 (TTY: 711).
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(Chinese) 711)。
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(Vietnamese) dành cho quý vị. Gọi số 1-800-332-0366 (TTY: 711).
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(Tagalog - tulong sa wika nang walang bayad. Tumawag sa 1-800-332-0366
Filipino) (TTY: 711).
Русский ВНИМАНИЕ: Если вы говорите на русском языке, вам доступны бесплатные услуги
(Russian) перевода. Звоните 1-800-332-0366 (телетайп: 711).
العربية 1-800-332-0366 (TTY: 711) اتصل على. تتوفر خدمات المساعدة للغوية المجانية، إذا كنت تتحدث العربية:يرجى االنتباه
(Arabic)
Kreyòl Ayisyen ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis èd nan lang ki disponib gratis pou ou. Rele
(French Creole) nimewo 1-800-332-0366 (TTY: 711).
Français ATTENTION : si vous parlez français, des services d’assistance linguistique vous sont
(French) proposés gratuitement. Appelez le 1-800-332-0366 (ATS: 711).
Polski UWAGA: jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń
(Polish) pod numer 1-800-332-0366 (TTY: 711).
Português ATENÇÃO: se você fala português, encontram-se disponíveis serviços linguísticos gratuitos. Ligue
(Portuguese) para 1-800-332-0366 (TTY: 711).
Italiano ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica
(Italian) gratuiti. Chiamare il numero 1-800-332-0366 (TTY: 711).
Deutsch ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlose Dienste für die
(German) sprachliche Unterstützung zur Verfügung. Rufnummer: 1-800-332-0366 (TTY: 711).
日本語 注意事項：日本語をお使いの方は、言語面でのサポートを無償でご利用いただけます。
(Japanese) 1-800-332-0366（TTY: 711）まで、お電話にてご連絡ください。
فارسی با. تسهيالت زبانی بصورت رايگان برای شما فراهم می باشد، اگر به زبان فارسی صحبت می کنيد:توجه
(Farsi) .تماس بگيريد1-800-332-0366 (TTY: 711)
