Completing this form correctly is essential for having your dental claim processed without delays. Whether you are pre-authorizing an upcoming dental procedure or requesting reimbursement for a completed treatment, follow the steps below to fill out the form and submit it to the DC 37 Health and Security Plan.
How to Fill Out the DC 37 Dental Form Step by Step
- Member Information: Enter your full name, Social Security Number or Personal Identification number, home address, and contact phone number. All details must match your DC 37 Health and Security Plan membership records.
- Patient Information: If the patient is not the member, provide the patient's name, date of birth, home address, and their relationship to the member. For dependent dental coverage in New York, this step is required.
- Provider Information: Your dentist fills in their name, office address, telephone number, and license number. Confirm the dentist participates in the DC 37 dental health plan network before you schedule the appointment.
- Treatment Details: List each dental procedure with the correct tooth number, surface code, procedure description, and the dentist's fee. Enter the total treatment charge at the bottom of this section.
- Orthodontia or Prostheses: For orthodontic treatment or replacement of prostheses, check the required boxes and attach any supporting documentation the plan requests.
- Signature and Payment Authorization: Sign the form and indicate whether the health plan should pay your dentist directly or send the reimbursement check to you. Your signature also authorizes the plan to use your protected health information for claim processing.
- Submit the Form: Mail or deliver the completed form to DC 37 Health and Security Plan, 125 Barclay Street, New York, NY 10007, or call (212) 815-1234 for submission options.
Frequently Asked Questions
Who can submit a DC 37 dental claim?
Members of District Council 37 and their eligible dependents enrolled in the DC 37 Health and Security Plan can submit dental claims. Contact the plan office to confirm your dependents are covered under your health benefits.
How do I find a participating dentist in New York?
DC 37 works with the Delta Dental network to give members access to thousands of dentists across New York and nationwide. Call (212) 815-1234 or visit the health plan office to get a list of participating dentists near you.
Is pre-authorization required before seeing a dentist?
Pre-authorization is required for certain procedures, including orthodontia and replacement of prostheses. For routine dental care such as cleanings or fillings, contact the plan at (212) 815-1234 to confirm whether your specific treatment needs prior approval.
What if my dental claim is denied?
If the DC 37 health plan denies your claim, you can file an appeal. Contact Member Services at the plan office in New York and request a formal review. Keep all documentation from your dentist, including itemized bills and treatment notes, to support the appeal.
Related Dental Claim Forms
If you need to file dental claims with other health plans, these forms may also be helpful:
- ADA Dental Claim Form - The standard dental claim form accepted by dentists and insurers nationwide
- Dental Claim Form J430d - Used by Delta Dental participating dentists to submit service claims
- Guardian Dental Claim Form - For members covered under Guardian dental insurance
- Health Plan Appeal Form - Use this to appeal a denied dental claim with your health plan