Dc 37 Dental Form – Fill Out and Use This PDF

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.