Csa Dental Form PDF Details

The CSA Dental Form is a dental assessment checklist that is used by dentists in the United States and Canada. The form was developed with input from more than 300 clinical faculty members, orthodontists, pediatric dentists, periodontists, public health professionals, oral surgeons and dental hygienist instructors. It has been updated to reflect current standards of care for both children and adults. This blog post will discuss the most recent updates made to the CSA Dental Form which includes new information on head circumference measurements in infants as well as updated instructions for taking intraoral photographs that reflect current technology advancements such as digital photography versus film photography.

Below is some information that could be beneficial in case you're seeking to learn how much time it'll take you to fill out csa dental form and what number of PDF pages it has.

QuestionAnswer
Form NameCsa Dental Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescsa retiree welfare fund forms, asonet dental claim form, asonet claim, csa welfare form

Form Preview Example

RETURNTO:

PLEASE CHECK

Dental Claim Form APPROPRIATE BOX TO CSAWELFAREFUND

CSARETIREEWELFAREFUND

SELF-INSURED DENTAL SERVICES

Dept 15

INDICATE MEMBER

STATUS

DCC/CSAWELFAREFUND(DayCare)

PO Box 9005

Lynbrook,NY11563-9005 (516)396-5500/(718)204-7172 www.asonet.com

 

 

PRE-TREATMENTESTIMATE

PLEASE SUBMIT PRE-OPERATIVE PERIAPICAL X-RAYS FOR

 

 

 

INLAYS, CROWNS, BRIDGES, DENTURES, PERIO SURGERY,

(REQUIRED FOR INLAYS, CROWNS, LAMINATE VENEERS,

ROOT THERAPY AND NON-ROUTINE EXTRACTIONS. X-RAYS

BRIDGES, DENTURES, PERIODONTAL SURGERY, OR WHEN

OF FULL ARCH REQUIRED FOR ALL BRIDGE WORK. POST

EXPENSES WILLEXCEED$300INA 90 DAY PERIOD)

TREATMENT X-RAYS REQUIRED FOR ALL ROOT THERAPY

 

 

PAYMENT CLAIM

 

 

CLAIMS.

 

 

 

 

 

 

PATIENT INFORMATION (REQUIRED ON CLAIMS FOR MEMBERS, SPOUSES, AND DEPENDENTS)

Patient Name

Birth date

Relationship to Member

 

Member

Spouse

Child

Other

If Full Time College Student: School, City

MEMBERINFORMATION (REQUIRED ON ALL CLAIMS)

(You may indicate only the last 4 digits)

MemberName

Birth date

Sex

 

 

Social Security #

-

-

 

HomeAddress

 

 

City

State

 

Zip

 

Telephone#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WorkLocation

WorkTelephone#

CheckTypeofMedicalCoverageYouhaveSelected

 

Are you covered for dental benefits by any other group plan or

 

 

 

 

 

 

 

H.I.P/HMO

G.H.I. Type C

G.H.I. - CBP

OTHER

government agency?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NameofOtherCompany/OrganizationProvidingBenefits

 

 

 

 

 

Policy/Plan Number

 

 

 

Start date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPOUSE INFORMATION (REQUIRED ON CLAIMS FOR SPOUSES AND DEPENDENTS)

Spouse'sName

Spouse's Birth date

Spouse's Social Security #

 

 

 

Is spouse covered by another Dental Benefits Plan?

Yes

 

No

Name, Address, Telephone # of Spouse's Employer (MUST BE COMPLETED OR CLAIM WILL BE RETURNED)

DENTIST INFORMATION (TO AVOID DELAY BE SURE TO ENCLOSE X-RAYS, PERIO CHARTING, PRIMARY VOUCHERS, ETC.)

Dentist's Name (Print)

License#

Telephone#

TaxpayerID#

StreetAddress

City

State

ZipCode

IfProsthesis,isthisinitialplacement?

 

DateofPrior Placement

ReasonforReplacement

 

IS THIS CLAIM THE RESULT OF:

Accident Injury?

Yes

No

Yes

No

 

 

 

 

 

 

 

Occupational Injury?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

DENOTE MISSING TEETH WITH AN "X"

Date

Tooth#

Surface

ADA

DescriptionofService

 

 

 

 

 

 

Service

or

CODE

(includingradiographs,prophylaxis,

 

 

Fee

 

 

 

 

 

 

 

 

 

Performed

Letter

 

 

 

materialsused,etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASECHARTPROPOSED

OR RENDERED TREATMENT

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR FUND, 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.

TOTAL FEE CHARGED

I hereby certify the accuracy of the procedures and dates of completion as listed above.

Signed (Dentist)

 

Date

 

AUTHORIZATIONTORELEASEINFORMATION:

I hereby authorize any insurance company, prepayment organization, employer, hospital, or dentist, to release all information with respect to myself or any of my dependents which may have a bearing on the benefits payable under this or any other plan providing benefits or services. I certify that the information submitted by me in support of this claim is true and correct. Authorization must be signed or payment will not be made.

Patient Signature(or member or spouse if patient is a minor)

 

Date

 

ASSIGNMENT OF BENEFITS: I hereby authorize payment of the benefits (otherwise payable to me) directly to the above named dentist. I understand I am financially responsible to the dentist for charges not covered by this authorization.

Patient Signature (or member or spouse if patient is a minor)

 

Date

You may photocopy this claim form or use universal claim forms. Please feel free to access our website at www.asonet.com

How to Edit Csa Dental Form Online for Free

Completing the asonet dental file is easy using our PDF editor. Keep up with the following steps to get the document ready without delay.

Step 1: Select the orange button "Get Form Here" on the page.

Step 2: The form editing page is currently open. You can include text or update current data.

Make sure you provide the next information to complete the asonet dental PDF:

part 1 to completing csa welfare fund nyc

Fill out the DENTIST INFORMATION, TO AVOID DELAY BE SURE TO ENCLOSE, Dentists Name Print, License, Telephone, Taxpayer ID, Street Address, City, State, Zip Code, If Prosthesis is this initial, DENOTE MISSING TEETH WITH AN X, Date of Prior Placement, Reason for Replacement, and IS THIS CLAIM THE RESULT OF fields with any particulars which may be asked by the system.

Entering details in csa welfare fund nyc step 2

You may be requested to type in the particulars to help the program prepare the section Signed Dentist AUTHORIZATION TO, Patient Signature or member or, Date, Patient Signature or member or, Date, and You may photocopy this claim form.

Filling in csa welfare fund nyc part 3

Step 3: Select "Done". You can now upload the PDF document.

Step 4: Ensure you prevent upcoming difficulties by having minimally 2 copies of the file.

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