Mail Completed Dental Claim Form - Barnard College (Page 2 of 2) in pdf

GHI DENTAL INSURANCE CLAIM FORM SIDE 2

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 a/so be subject to a civi/ pena/ty not to

exceed five thousand dollars and the stated va/ue of the c/aim for each such vio/ation.

INSTRUCTIONS:

Mail the CLAIM FORM promptly.

Follow these instructions to avoid delay.

4. If you use a GHI Participating

Dentist,

payment

will

be made directly to the dentist.

1. Complete

sections A and B in full to assure positive

identification and prompt payment.

5. Dental coverage

is subject to specific

limitations

and

exclusions.

Please

refer to your

insurance

booklet

and certificate

for a description

of covered

services,

limitations and exclusions.

2. The Subscriber must sign and date the claim

3. All Claim forms must be submitted

to GHI no later

than 180 days after the end of the calendar

year

in which the service was rendered.

6. This form will have to be returned

if it is incomplete

or incorrect.

I CERTIFY

THAT'MY

DEPENDENT,

MEETS

ALL

REQUIREMENTS

FOR

ELIGIBILITY

AS A DEPENDENT

STUDENT,

YES

~ ~-

-c-iW

IF GRADUATED. GIVE DATE

I DATE STARTED

HAS DEPENDENT

SERVED IN THE ARMED FORCES?

IF YES, GIVE DATES OF SERVICE.

YES

FROM

A. 19 YEARS OF AGE OR OLDER

B. UNMARRIED

C. RECEIVES

MORE THAN HALF OF SUPPORT

FROM THE

EMPLOYEE

OR RETIRED

EMPLOYEE

D. IS A FULL- TIME STUDENT AT AN ACCREDITED

SECONDARY

OR PREPARATORY

SCHOOL OR COLLEGE

E. EXPECTED

DATE OF GRADUATION

DATE

lf dependent over age 19 is disabled and eligibility has not been established, contact your Health Benefits Administrator, personnel department or

business office for special form.

~12S

D437B

SOOM 1/97

Mail Completed Dental Claim Form - Barnard College Page 2

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