Uft Welfare Fund Contact – Fill Out and Use This PDF

MEMBER INFORMATION - See instructions on reverse side

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Member Name (Please Print)

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Sex

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Home Address

City

State

Zip Code

Telephone #

(

)

School or Bureau

ISchool Telephone #

IDo you have G.H.L medical coverage?

{

)

DYes

0

No

Name and Address of Other Company/Organization Providing Dental Benefits under which you are covered

PATIENT INFORMATION

Patient Name (Please Print)

Relationship to Member

SPOUSE/DOMESTIC PARTNER INFORMATION - (Required if claim is for Spouse/Domestic Partner or Dependent Child)

Spouse/Domestic Partner Name (please Print)

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Partner

I ISpouselDomestic Partner Social Security II

.

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Is spouse/domestic partner covered by another Dental Benefits Plan other than UFTWF? o Yes

o No If yes. specify below.

Name and Address of Other Company/Organization Providing Dental Benefits

ICompany/Organization Telephone #

(

)

Signed (Patient or Parent if Minor)

Date

Dentist's Name (please Print)

IUcense#

Taxpayer 10 II

Street Address

City

State

Zip Code

Telephone II

(

)

If prosthesis, is this the initial placement?

Date of Prior Placement

o Yes 0 No If no. the reason for replacement

DENOTE MISSING TEETH WITH AN "X"

Are radiographs enclosed? If yes, how many? 115 this claim the result of: Accident Injury 0 Yes

0 No

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DVes ONo

Motor Vehicle Injury

0

Yes 0 No

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PATIENT'S NAME

AGE:

Tooth #

Surtace

Description of Service

Date Service

Procedure

Fee

or letter

(including materials used)

Performed

Code

TOTAL FEE

Signed {Dentist)

Oate

CHARGED