Standard Dental Claim Form PDF Details

Are you tired of submitting the same cumbersome paperwork required to process your dental insurance claim? Understanding what information is needed on a standard dental insurance claim form can be overwhelming, leaving you feeling frustrated and unsure of how to proceed. At XYZ Dental Agency, we understand your frustration and are here to provide insight into understanding and completing the mandatory components of a standard dental insurance claim form.

Question	Answer
Form Name	Standard Dental Claim Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	standard ada form, standard dental claim form, SEPERATELY, claim

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STANDARD DENTAL

CANADIAN LIFE AND HEALTH

CLAIM FORM

INSURANCE ASSOCIATION INC.

UNIQUE NO.

SPEC.

PATIENTS OFFICE ACCOUNT NO.

PART 1 DENTIST

I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM

TO THE NAMED DENTIST AND AUTHORIZE PAYMENT TO

HIM/HER

PHONE NO.

SIGNATURE OF SUBSCRIBER

FOR DENTIST USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES,OR SPECIAL CONSIDERATIONS.

I UNDERSTAND THAT THE FEES LISTED IN THIS CLAIM MAY NOT BE COVERED BY OR MAY EXCEED MY PLAN

BENEFITS. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO MY DENTIST FOR THE ENTIRE TREATMENT.

I ACKNOWLEDGE THAT THE TOTAL FEE OF $

IS ACCURATE AND HAS BEEN CHARGED TO ME FOR

SERVICES RENDERED.

I AUTHORIZE RELEASE OF THE INFORMATION CONTAINED IN THIS CLAIM FORM TO MY INSURING COMPANY /

PLAN ADMINISTRAT O R. I ALSO AUTHORIZE THE COMMUNICATION OF INFORMATION RELATED TO THE COVERAGE

OF SERVICES DESCRIBED IN THIS FORM TO THE NAMED DENTIST.

SIGNATURE OF PATIENT (PARENT/GUARDIAN)

OFFICE VERIFICATION

DATE OF SERVICE

PRO-

INTL.

DAY

MO.

YR.

CEDURE

TOOTH

DENTIST’S

LABORATORY

FOR CARRIER USE

CODE

SURFACES

FEE

CHARGE

TOTAL CHARGES

ALLOWED AMOUNT

INC

PATIENT’S SHARE

CHEQUE NO.

DATE

THIS IS AN ACCURATE STATEMENT OF SERVICES PERFORMED AND THE TOTAL FEE DUE AND PAYABLE, E & OE.

INSTRUCTIONS FOR CLAIM SUBMISSION

DEDUCTIBLE	PATIENT PAYS	PLAN PAYS

CLAIM NO.

TOTAL FEE SUBMITTED

BEING A STANDARD FORM, THIS FORM CANNOT INCLUDE SPECIFIC INSTRUCTIONS ON WHERE IT SHOULD BE SENT, DEPENDING ON WHO IS THE CARRIER FOR YOUR PLAN. YOU CAN OBTAIN DETAILS FROM EITHER YOUR PLAN BOOKLET, YOUR CERTIFICATE OR FROM YOUR EMPLOYER.

IF YOU PLAN REQUIRES SUBMISSION DIRECTLY TO THE CARRIER, PLEASE SEND THIS FORM WITH ONLY PARTS 1, 2 AND 3 COMPLETED TO THE CARRIER’S APPROPRIATE CLAIMS OFFICE.

*IF YOUR PLAN REQUIRES SUBMISSION TO YOUR EMPLOYER, PLEASE DIRECT THIS FORM TO YOUR PERSONNEL OFFICE/PLAN ADMINISTRATOR WHO WILL COMPLETE PART 4 AND FORWARD THE FORM TO THE CARRIER.

PART 2 - EMPLOYEE/PLAN MEMBER/SUBSCRIBER

1.GROUP POLICY/PLAN NO._____________________________DIVISION/SECTION NO.______________________

EMPLOYER _________________________________________________________________________________

NAME OF INSURING AGENCY OR PLAN ___________________________________________________________

PART 3 - PATIENT INFORMATION

1. PATIENT: RELATIONSHIP TO EMPLOYEE/

PLAN MEMBER/SUBSCRIBER _________________________________________________________

DATE OF BIRTH _________________________ IF CHILD INDICATE: ❏STUDENT ❏HANDICAPPED

DAY	MONTH	YEAR
IF STUDENT, INDICATE SCHOOL ________________________________________________________
PATIENT I.D. NO. ____________________________________________________________________
2. ARE ANY DENTAL BENEFITS OR SERVICES PROVIDED UNDER ANY OTHER GROUP INSURACE OR DENTAL
PLAN, W.C.B. OR GOV’T PLAN?	❏ NO	❏ YES

POLICY NO. ____________________________ SPOUSE DATE OF BIRTH ______________________________

NAME OF OTHER INSURING AGENCY OR PLAN ___________________________________________________

2.YOUR NAME (PLEASE PRINT) ___________________________________________________________________

YOUR CERT. NO. OR S.I.N. OR I.D. NO. ______________________________________________________________

YOUR DATE OF BIRTH ___________________________________________
	DAY	MONTH YEAR
3.	IS ANY TREATMENT REQUIRED AS THE RESULT OF AN ACCIDENT?		❏ NO	❏ YES
	IF YES, GIVE DATE AND DETAILS SEPERATELY.
4.	IF DENTURE, CROWN OR BRIDGE, IS THIS INITIAL PLACEMENT?		❏ NO	❏ YES
	GIVE DATE OF PRIOR PLACEMENT AND REASON FOR REPLACEMENT.		❏ NO	❏ YES
	GIVE DATE OF PRIOR PLACEMENT AND REASON FOR REPLACEMENT.
5.	IS ANY TREATMENT REQUIRED FOR ORTHODONTIC PURPOSES?		❏ NO	❏ YES

6.I AUTHORIZE THE RELEASE OF ANY INFORMATION OR RECORDS REQUESTED IN RESPECT OF THIS CLAIM TO THE INSURER / PLAN ADMINISTRATOR AND CERTIFY THAT THE INFORMATION GIVEN IS TRUE, CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

DATE _________________________

DAY MONTH YEAR

___________________________________________________

SIGNATURE OF EMPLOYEE/PLAN MEMBER/SUBSCRIBER

PART 4. - POLICY HOLDER/EMPLOYER (FOR COMPLETION ONLY IF APPLICABLE. SEE ABOVE*)

DAY

1.DATE COVERAGE COMMENCED

2.DATE DEPENDENT COVERED

3.DATE TERMINATED

MONTH

YEAR			DATE

	4. CONTRACT HOLDER				AUTHORIZED SIGNATURE
		DAY	MONTH	YEAR

					(POSITION OR TITLE)

ALL INFORMATION RECORDED ON THIS FORM IS CONFIDENTIAL

Standard Dental Claim Form – Fill Out and Use This PDF

Standard Dental Claim Form PDF Details

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Standard Dental Claim Form – Fill Out and Use This PDF

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