Humana Dental Forms Details

Dental insurance is an important part of maintaining your oral health, and Humana offers a variety of dental plan options to fit your needs. Their Dental Form is a simple, one-page document that lets you compare different dental plans and choose the one that’s right for you. The form includes information on coverage, premiums, and provider networks, so you can make an informed decision about your dental care. Plus, it’s easy to fill out – all you need are the details on your current dental coverage. If you’re looking for a new dental plan or just want to compare your options, the Humana Dental Form is a great resource.

In the list, there's some information regarding the humana dental form. You will have the estimated time it will take you to fill out the form as well as additional details.

QuestionAnswer
Form NameHumana Dental Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshumana dental forms, human dental claim form, dental claim form for humana, humana dental form pdf

Form Preview Example

ADA Dental Claim Form STANDARD 2007

ATTENDING DENTIST’S STATEMENT

Header information

1.Type of transaction (mark all applicable boxes)

Statement of actual services

EPSDT/Title XIX

Request for predetermination / preauthorization

2.Predetermination/preauthorization number

Insurance company / dental benefit plan information

3. Company/plan name, address, city, state, ZIP code

Other coverage

4.

Other dental or medical coverage? No (Skip 5-11) Yes (Complete 5-11)

 

 

 

5.

Name of policyholder/subscriber in #4 (Last, First, Middle Initial, Suffix)

 

 

 

 

 

6.

Date of birth (MM/DD/YYYY)

7. Gender

8. Policyholder Subscriber ID #

 

 

M F

 

 

 

 

 

9.

Plan/group number

10. Patient’s Relationship to Person Named in #5

 

 

Self

Spouse

Dependent/Other

11. Other insurance company/plan name, address, city, state, ZIP code

MAIL THIS FORM TO: HumanaDental Claims Office

PO Box 14611

1-800-233-4013 Lexington, KY 40512-4611

Policyholder / subscriber information

12.Subscriber name, address, city, state, ZIP code

13.Date of birth (MM/DD/YYYY) 14. Gender

M F

15. Policyholder ID#

16. Plan/group number

17.Employer name

Patient information

18. Relationship to policyholder above 19. Student Status Self Spouse Dependent/Other FTS PTS

20.Patient name, address, city, state, ZIP code

21.Date of birth (MM/DD/YYYY) 22. Gender

M F

23. Patient ID #/Acct #

Record of services provided

 

24. Procedure date

 

25. Area of

 

26. Tooth

 

 

27. Tooth number(s)

28. Tooth

29. Procedure

 

 

30. Description

 

 

 

 

 

 

31. Fee

 

(MM/DD/YYYY)

 

oral cavity

 

 

system

 

 

or letter(s)

 

 

 

surface

 

code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Missing teeth information

 

 

 

 

 

 

 

 

 

 

Permanent

 

 

 

 

 

 

 

 

 

 

 

 

Primary

 

 

 

 

32. Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fee(s)

 

34. Place an ‘X’ on each

 

1

2

 

3

4

 

5

 

6

7

 

8

9

10

11

12

13

14

15

16

 

A

 

B

C

D

E

F

G

H

I

J

 

 

 

33. Total

 

missing tooth

 

32

31

30

29

 

28

 

27

26

 

25

24

23

22

21

20

19

18

17

 

T

 

S

R

Q

P

O

N

M

L

K

 

 

 

 

 

 

 

Fee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

35. Remarks

Authorizations

36.

Patient signature

Date

X

 

 

 

 

 

37.

Subscriber signature authorize payment

Date

X

 

 

 

 

 

Billing dentist or dental entity

48. Name, address, city, state, ZIP code

49. NPI

50. License #

51.SSN or TIN

52.Phone number

52A. Additional provider ID #

Please note: Pretreatment Review is not a guarantee of benefits payable.

Ancillary claim/treatment information

38.

Place of treatment:

39. Number of enclosures:

40. Is treatment for Orthodontics?

 

Clinic Hospital

 

X-Rays Models

No

Yes

 

 

 

 

 

41.

Date appliance placed

 

42.

Months of treatment remaining

 

 

 

 

43.

Replacement of prosthesis?

44.

Date Prior Placement (MM/DD/YYYY)

 

No Yes

 

 

 

 

 

 

 

 

 

45.

Treatment Resulting from: Occupational Illness

Auto

Other Injury

 

 

 

 

 

 

46.

Date of Accident

 

47.

Auto Accident State

 

 

 

 

Treating dentist and treatment location

 

 

 

 

 

 

 

 

 

53.I hereby certify that the procedures as indicated by (print name):

X

54. NPI

55. Address, city, state

 

 

 

 

This estimate advises you in advance of the amount of insurance benefits payable if the described procedures are performed during a period of the patient’s eligibility.

GN-00229-HD 6/07

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