Mail Completed Dental Claim Form - Barnard College

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MAIL COMPLETED DENTAL CLAIM FORM TO:
GHI
P.O. Box 2838
New York NY 1 0116- 2838
CATEGORY IGROOP
lTPATIENrs
RRSr
NAME
2. PATIENT'S DATE OF BIRTH
I
MONTHJ DAY1Y~AR
1, SUBSCRIBER'SCERT!FICATENUMBER
~
~
3. PATIENT'S RELATIONSHIP TO SUBSCRIBER
0
'
c
'
0
00"
0:
SUBSCRIBER
SPOUSE
SON
OAUGHTEROmEf!:SPECIFY
12
3
4
(SPATIENT A DISABLED DEPENDENT OVERAGE 19?
"
~o
NO
It Yes, see H on reverse.
I ",-IS PATIENT A DEPENDENT STUDENT AGE 19 OR OVER? IF YES, PART G (DEPEN-
DENT STUDENT INFORMATION) ON THE REVERSE SIDE MUST BE COMPLETED.
6a. WAS CONDITION RELATED TO PATIENT'S EMPLOYMENT?
tib. WAS CONDITION RELATED TO AN AUTO ACCIDENT?
6c. WAS CONDITION RELATED TO OTHER ACCIDENT?
FIRST
~
I
OMALE
:'!
APT.
NO.
NO.AND sTREET
YES
-
NO
CITY
STATE
ZIP CODE
AREA CODE
TELEPHONE NUMBER
0 YES
'0 NO
3a. IS THE SUBSCRIBER'S
D
YES
3b. DOES THE SUBSCRIBER OR SPOUSE HAVE
SPOUSE EMPLOYED?
D
NO
ADDITIONAL DENTAL INSURANCE COVERAGE?
IF ,\:OU ANSWERED YES TO EITHER QUESTION 3a. OR 3b.,
PART F (OTHER INSURANCE COVERAGE) ON F!EVERSE SIDE MUST BE COMPLETED.
Any
person
who
knowingly
and
with
intent
to defraud
any
insurance
company
or
other
person
files
an application
for
insurance
or statement
of claim
concerning
any
materially
false
information,
or
conceals
for
the
purpose
of
misleading,
information
concerning
any
fact
material
thereto,
commits
a fraudulent
insurance
act,
which
is a crime,
and
shall
also
be subject
to a civil
penalty
not
to exceed
five
thousa"d
dollars
and
the
stated
value
of
the
claim
for
each
such
violation.
I CERTIFY THAT THE INFORMATION
GIVEN IS CORRECT AND AUTHORIZE
RELEASE, TO OR BY GHI,
NOT AVAILABLE
UNDER
ANY
OTHER
GROUP
PLAN
EXCEPT
AS
INDICATED-ABovE
~
Your
contract
may
-,
commencement
of orthodontics,
prosthetics
and
surgeries.
Please
refer
to your
benefits
brochure
to determine
if predetermination
of benefits
is required.
If so,
have
your
dentist
complete
Part
D of this
form.
Check
the
appropriate
box
in Section
7, submit
x-rays
if
~~~~~~~i~~ajl~~?e.mail
to GHI.
GHI
will
notify
thedentis:a~~~u~scri~ero~the
=O"m-of~
eA,,"",
OR",,"°"'.'
"",,ru..
(,-
.,""=.",
DATE
1. DENTIST
NAME
(IF NO, REASON FOR REPLACEMENT)
DATE OF PRIOR
PLACEMENT
MAILING ADDRESS
IF SERVICES
DATE APPLIANCE PLACED'
MOS. TREATMENT
ALREADY
REMAINING
COMMENCED
ENTER:
I AM A SPECIALIST
IN:
D ORTHODONTICS
D ENDODONTICS
CITY, STATE, ZIP CODE
2.
DENTIST
TAX
IDENTIFICATION
NO.
--
5. IF PROSTHESIS
AND/OR
CROWN.
O
YES
IS THIS INITIAL
PLACEMENT?
O
NO
6. IS THIS TREATMENT
YES
FOR ORTHODONTICS?
D
ONO
I DENTIST LICENSE NO.
DORALSURGERY
DPERIODONTICS
DOTHER
3. FIRST VISIT DATE
PLACE OF TREATMENT
RADIOGRAPHICS OR
I
NO
I
YES
I
HOW
CURRENT SERIES
OFFICE, HOSP OR OTHER
MODEL ENCLOSED?
MANY?
7. CHECK
ONLY
ONE
D
DENTIST'S
STATEMENT
OF ACTUAL SERVICES:
I hereby certify that the procedures
below were rendered and completed on the dates indicated
D
DENTIST'S
TREATMENT
PLAN (PRE-DETERMINATION
OF BENEFITS).
4. PARTICIPATING
DENTIST
IN A GHI
PLAN
D
YES
nNO
.,
,
TO BE COMPLETED
BY A PARTICIPATING
DENTIST
ONLY:
I HAVE
BEEN
PAID
D
YES (AMOUNT
PAID) $
-
DNO
1
D!
WAS NOTIFIE-DBEFO~E-S-E~I~~S-~E~E-RE~ERE~~~G!:!!!!!S~R~!A
DATE

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