Dc 37 Dental Form PDF Details

Navigating the intricacies of dental health care can sometimes feel overwhelming, but for members of District Council 37 (DC 37), the Dental Form provides a structured and detailed guide to ensure necessary dental procedures are covered effectively. Located at 125 Barclay Street, New York, with a communication line always open at (212) 815-1234, this form serves as a pivotal tool for both pre-authorization and claiming completed dental services. It meticulously collects member information, including Social Security Number or Personal Identification, gender, and full name, alongside detailed patient information such as address, relationship to the member, and birthday. The form extends to incorporate provider details, conditions for orthodontia treatments, and specifics regarding replacement of prostheses. With sections dedicated to the finer details of treatment, including tooth numbering and surfaces, procedures with their corresponding fees, and total treatment charges, the aim is to streamline the paperwork process. Notably, members are required to sign the form, making a choice between direct payment to themselves or to the dentist, emphasizing the importance of consent in the disclosure and use of protected health information for claim processing. This comprehensive form underscores the commitment to facilitating efficient and transparent access to dental care for the members of DC 37.

QuestionAnswer
Form NameDc 37 Dental Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdelta dental insurance dc37, 37 dental dc, dc37 delta dental list, ny form dc37

Form Preview Example

DISTRICT COUNCIL 37 HEALTH AND SECURITY PLAN 125 BARCLAY STREET, NEW YORK, N.Y. 10007-2179 (212) 815-1234

 

MEMBER INFORMATION:

 

 

 

 

 

 

 

 

 

 

 

PRE -AUTHORIZATION --OR--

 

 

 

 

 

 

 

 

Member SSN/PID:

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender:

 

M

 

F

 

 

CLAIM FOR COMPLETED SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last/First Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT INFORMATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient First Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C/O Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Birthday:

 

 

 

 

 

 

 

 

 

Gender:

M F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship:

 

Self

 

 

Spouse/Domestic Partner

 

 

 

Child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

 

Birthday:

 

 

 

 

 

PROVIDER INFORMATION:

 

 

 

 

 

 

 

 

 

Employer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last/First Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPOUSE / DOMESTIC PARTNER INFORMATION:

 

 

City/State/Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse SSN:

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender:

 

M

 

F

Tax ID#:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last/First Name:

 

 

 

 

 

 

 

 

 

 

 

Birthday:

 

 

 

 

NPI #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Co.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Participating Panel Dentist:

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Orthodontia Treatment Appliance Insertion Date:

 

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Replacement of Prothesis:

 

YES

NO

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TREATMENT INFORMATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERMANENT:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DECIDUOUS:

 

 

 

 

 

1 2 3

4 5

 

6

7

8

9

 

10

11 12 13 14

15

16

 

 

PLACE AN "X"

 

A B C D

E

F G H

 

I

J

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ON EACH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32 31 30 29 28 27

26

25

24

 

23

22 21 20 19 18 17

 

 

MISSING TOOTH

 

T S R Q P O N M L

K

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tooth

 

 

Oral

 

 

Tooth

 

Surfaces

 

Date

 

 

Procedure

 

 

Procedure

 

 

 

 

 

 

Fee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

System

 

Cavity

 

Number

 

 

 

 

 

of Service

CDT Code

 

 

Description:

 

 

 

 

 

 

Charge

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Remarks:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Treatment Charges:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALL CLAIM FORMS SHOULD BE FULLY COMPLETED, SIGNED, AND RETURNED TO THE PLAN OFFICE AT THE ABOVE LISTED ADDRESS.

 

 

 

 

 

 

 

MEMBER MUST SIGN AND CHECK ONE BOX ONLY, INDICATING PAYMENT TO MEMBER OR DENTIST FOR CLAIMS FOR COMPLETED SERVICE.

 

 

 

 

 

 

 

 

 

 

 

To the extent permitted by law, I consent to your use

Member's Signature is required on all claim forms, photocopy of

I certify that my submittal of the Pre-Authorization Plan or

 

and disclosure of my protected health information to

 

signature is not acceptable. I hereby verify that the Pre-

 

Claim for Completed Services, listing procedures indicated

 

carry out payment activities in connection with this

Authorization or Claim for Completed Services, listed procedures

by date, are accurate and that all services indicated by date

 

 

 

 

 

 

 

claim

 

 

 

 

 

 

 

with service dates are accurate and that all services indicated by

have been completed and furthermore I certify that all

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

date have been completed.

 

 

crowns, bridges, and dentures have been inserted.

______________________

 

 

__________

______________________

____________

______________________

 

____________

 

Patient/Guardian Signature

 

 

Date

 

 

Member's Signature

 

 

Date

 

 

Dentist's Signature

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR CLAIM FOR COMPLETED SERVICES

 

UNDER SECTION 6109 OF THE INTERNAL REVENUE CODE,

 

FOR DC37 USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECIPIENTS OF MEDICAL AND HEALTH CARE PAYMENT ARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Examiner: _________________________

 

Please make payment to

 

 

Member

 

REQUIRED TO FURNISH IDENTIFYING NO. TO PAYERS WHO

 

 

 

 

MUST REPORT SUCH PAYMENTS TO THE INTERNAL REVENUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

_________________________

 

Please make payment to

 

 

Dentist

 

SERVICE.