Tricare Retiree Dental Program Overseas Claim Form
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1
2TRICARE Retiree Dental Program
FEDERAL GOVERNMENT PROGRAMS
PO BOX 537006
Overseas Claim Form
SACRAMENTO, CA 95853-7006
UNITED STATES OF AMERICA
Primary enrollee information
10
(
,
,
)
primary enrollee name
last
first
mi
and address
Service type
1
-
completed services
statement of pre
determination
11
(
/
/
)
12
(
,
/
)
:
date of birth
mm
dd
yyyy
phone number
including country
city and
or area code
important
attach to this form the dentist
s receipt for
’
-
.
completed services or statement for pre
determination
13
-
14
e
mail address
gender
Other coverage
m
f
15
2
/
?
retiree social security number
is patient covered by another dental
medical plan
(
3-9)
no
skip
yes
3
/
(
,
,
)
Patient information
name of employee
policyholder
last
first
mi
16
(
,
,
)
patient name
last
first
mi
4
(
/
/
)
5
6
/
#
date of birth
mm
dd
yyyy
gender
employee ssn
id
m
f
17
(
/
/
)
18
19
-
,
date of birth
mm
dd
yyyy
gender
if full
time student
list school and city
7
relationship to patient
m
f
self
spouse
dependent
other
20
relationship to primary enrollee
8
8
a group number of other carrier
b amount paid group by other carrier
self
spouse
dependent
other
$
21
9
name and address of other carrier
i have reviewed the treatment plan and agree to be responsible for all charges for dental services not paid by my
.
dental benefit plan
i consent to your use and disclosure of my protected health information and authorize release
.
of any information relating to this claim
x
(
/
)
signature of patient
or parent
guardian
date
Dental services
22
(
. 1
. 32.
treatment plan
list in order from tooth no
through tooth no
using the charting system shown below
tooth guide
tooth number or
tooth surface
description
date of service
cdt procedure code
fee charged
(
/
/
)
letter
mm
dd
yyyy
1
2
3
4
5
6
7
8
9
10
23
24
$
remarks for unusual services
total fees charged
0
25
indicate currency
Dentist information
Additional claim information
26
27
32
33
dentist name
dentist number
number of radiographs enclosed
replacement of prosthesis
yes date of prior placement
28
34
office address
treatment resulting from
/
occupational illness
injury
auto accident
other accident
date
35
treatment related to orthodontics
29
(
,
/
)
phone number
including country
city and
or area code
yes
date appliance placed
total months of treatment
36
30
(
,
/
)
fax number
including country
city and
or area code
,
,
any person who knowingly files a statement of claim containing any misrepresentation or false
incomplete
or
,
,
,
misleading information
or who conceals
for the purpose of misleading
any information concerning any fact
31
-
,
/
e
mail address
material thereto
may be guilty of a criminal act under state and
or federal law and may also be subject to civil
.
(
penalties
i hereby certify that the procedures listed by date are in progress
for procedures that require multiple
)
.
visits
or have been completed
x
signature of dentist
date
TRDP Claim Form — Overseas 8/13
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