Dc 37 Dental Form – Fill Out and Use This PDF

The DC 37 Dental Form is a critical document for members of the District Council 37 Health and Security Plan, facilitating the pre-authorization or claims process for dental services. It includes sections for member, patient, provider, and treatment information, ensuring that all relevant details are captured for the processing of dental claims. By accurately completing and submitting this form, members can streamline their dental service claims, making it easier to receive the care they need.

Ready to take the next step in managing your dental health benefits? Click the button below to fill out your DC 37 Dental Form.

Get Form Now Download PDF

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.

Question	Answer
Form Name	Dc 37 Dental Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	delta 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:

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:

Tax ID#:

Last/First Name:

Birthday:

NPI #:

Employer Name:

Phone #:

Insurance Co.:

Participating Panel Dentist:

YES

Street Address:

Orthodontia Treatment Appliance Insertion Date:

Month

Day

Year

City/State/Zip:

Replacement of Prothesis:

YES

Month

Day

Year

TREATMENT INFORMATION:

PERMANENT:

DECIDUOUS:

1 2 3

4 5

11 12 13 14

PLACE AN "X"

A B C D

F G H

ON EACH

32 31 30 29 28 27

22 21 20 19 18 17

MISSING TOOTH

T S R Q P O N M L

Tooth

Oral

Tooth

Surfaces

Date

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.

Dc 37 Dental Form – Fill Out and Use This PDF

Dc 37 Dental Form PDF Details

Form Preview Example

Dc 37 Dental Form isn’t the one you’re looking for?

Related Documents