Nyc Pba 14 Form PDF Details

In navigating the maze of healthcare bureaucracy, the NYC PBA 14 Dental Claim Form emerges as a critical document for members of the Patrolmen’s Benevolent Association in New York City, ensuring they can claim dental benefits with relative ease. Located on Broad Street in New York, the PBA Funds Office acts as the beacon for those seeking to understand and utilize their dental benefits efficiently. This form, meticulously designed to capture the essence of the claim process, requires members to provide comprehensive details, ranging from personal identification to the nuanced specifics of the dental service received. Aspects such as the member’s social security number, the patient's relationship to the member, and the treatment details—right down to the tooth charting system—underscore the form’s attention to detail. Moreover, the requirement for the member's signature on all claims, the prohibition of spouse or photocopy signatures, and directives for including x-rays and other documentation for certain treatments emphasize the form's role in maintaining the integrity and accuracy of claims. The layout of the NYC PBA 14 form not only facilitates a streamlined submission but also incorporates safeguards like precertification requirements for specific dental works, mirroring the meticulous nature in which dental care is administered and billed. Through this lens, the form becomes not just a paper trail but a testament to the organized and member-focused approach of the Patrolmen's Benevolent Association towards healthcare benefits.

QuestionAnswer
Form NameNyc Pba 14 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform pba dental, nyc pba dental form, form pba claim, pba claim form

Form Preview Example

 

 

DENTAL CLAIM FORM

PATROLMEN ’S

 

 

BENEVOLENT

NYC PBA FUNDS OFFICE

 

ASSOCIATION

 

125 Broad Street, 11th Floor New York, N.Y. 10004

 

Of The City Of New York, Incorporated

212-349-7560

 

 

 

 

 

 

 

PLEASE PRINT - SEE REVERSE SIDE BEFORE COMPLETION

MEMBER COMPLETES

1.

MEMBER’S SOCIAL SECURITY NO.

 

 

 

2. MEMBER’S NAME (LAST, FIRST, MIDDLE INITIAL)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

MEMBER’S ADDRESS (NUMBER, STREET)

 

 

 

 

 

 

CITY

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

PATIENT’S FIRST NAME

 

5. PATIENT’S LAST NAME

 

 

 

6. PATIENT’S RELATIONSHIP TO MEMBER

 

7. PATIENT’S DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF SPOUSE DGHTR SON STEP-CHILD OTHER*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

DOES PATIENT HAVE OTHER HEALTH AND/OR DENTAL COVERAGE

NO

YES. IF YES, PLEASE GIVE THE FOLLOWING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY HOLDER’S NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NO.

 

 

 

 

 

 

NAME AND ADDRESS OF EMPLOYER/UNION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF INSURANCE CARRIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

MEMBER’S SIGNATURE IS REQUIRED ON ALL CLAIM FORMS, SIGNATURE OF SPOUSE OR PHOTOCOPY OF MEMBER’S SIGNATURE IS NOT ACCEPTABLE.

 

 

 

I HEREBY CERTIFY THAT ALL SERVICES LISTED BELOW WITH A DATE OF SERVICE HAS BEEN DONE AND/OR REQUEST PRE-CERTIFICATE FOR TREATMENT PLAN LISTED WITHOUT DATES OF SERVICE.

 

 

PLEASE MAKE REIMBURSEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACTIVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYABLE TO

MEMBER

DENTIST

 

SIGNATURE OF MEMBER

 

 

 

 

 

 

DATE

 

RETIRED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. DENTIST NAME

 

 

 

 

 

 

 

 

13. PHONE NO.

 

 

 

 

MEMBER’S HOME PHONE

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

(

 

)

 

 

 

 

11. DENTIST ADDRESS

 

 

 

NUMBER AND STREET

 

 

14. PRACTICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GENERAL

PERIO

ORTHO

ENDO

ORAL SURGERY

PROSTHO

PEDOD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. CITY

 

 

 

 

 

STATE

ZIP CODE

 

DENTIST TAX IDENT. NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TAX

S.S.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DENTIST

 

 

 

 

 

 

 

EXAMINATION AND TREATMENT RECORD — USE CHARTING SYSTEM SHOWN

 

 

 

 

 

 

 

TOOTH

 

 

DESCRIPTION OF SERVICE (INCLUDING X-RAYS

 

DATE SERVICE

PROCEDURE

 

FUND USE

 

 

INDICATE MISSING

 

 

 

 

 

 

OR

SURFACE

 

PERFORMED

FEE

 

 

 

 

 

 

PROPHYLAXIS, MATERIALS USED ETC.)

 

 

CODE

 

ONLY

 

 

TEETH WITH AN X

LETTER

 

 

 

 

MO. DAY. YR.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETES

 

PRINT

 

 

LINE

 

 

 

DENTIST

PLEASEPROCEDURE

ONE

PER

 

 

 

 

 

15. ARE X-RAYS ENCLOSED

 

 

 

YES

 

 

 

NO

 

 

 

IF YES, HOW MANY?

 

 

 

 

16. IF PROSTHESIS, IS THIS

17. IF NO, REASON FOR

 

18. DATE OF PRIOR PLACEMENT

 

TOTAL

 

 

 

THE INITIAL PLACEMENT

 

REPLACEMENT

 

 

 

 

 

 

 

FEE

 

 

 

YES

NO

 

 

 

 

 

 

 

 

CHARGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. I CERTIFY THAT THE PROCEDURES INDICATED WILL BE OR HAVE BEEN COMPLETED

 

 

TOTAL BENEFIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.O.B.

 

 

 

SIGNED (DENTIST)

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR

 

EXAM

 

AUDIT

 

CODE

 

X-RAY

 

DENTIST PROFILE

REMARKS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PBA-14 (Rev. 2/03)

(SEE OTHER SIDE )

INSTRUCTIONS

PRECERTIFICATION IS REQUIRED FOR ALL CROWN AND BRIDGE, PROSTHETIC, ORTHODONTIC, AND PERIODONTIC WORK.

DENTIST:X-RAYS MUST BE SUBMITTED WITH ALL CLAIMS REQUESTING PRECERTIFICATION.

STUDY MODELS ARE ALSO REQUIRED FOR ALL

ORTHODONTIC CLAIMS.

PERIO CHARTING IS REQUIRED FOR ALL

PERIODONTIC CLAIMS

MEMBER:DO NOT ALLOW YOUR DENTIST TO COMMENCE ANY PROCEDURES WHERE PRECERTIFICATION IS REQUIRED UNTIL BOTH YOU AND YOUR DENTIST HAVE RECEIVED THE PRECERTIFICATION.OTHERWISE, YOU WILL BE LIABLE FOR PAYMENT OF SERVICES THAT MIGHT NOT BE APPROVED BY THE PLAN.

NOTE:ALL COMMUNICATIONS WITH THE FUNDS OFFICE MUST INCLUDE PATIENTS CLAIM NUMBER (WHEN KNOWN) OR MEMBERS SOCIAL SECURITY NUMBER.

IMPORTANT: FOR PROTECTION OF YOURSELF AND THE PBA FUNDS, PLEASE DO NOT SIGN BOX #9 ON THE FRONT OF THIS FORM UNTIL THOSE SERVICES ACTUALLY ARE PERFORMED OR THOSE REQUIRING PRECERTIFICATION HAVE BEEN FILLED-IN BY THE DENTIST.

ALL CLAIMS SUBJECT TO REVIEW FOR COORDINATION OF BENEFITS

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