Form D437b - Ghi Dental Claim Form
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1
2MAIL COMPLETED DENTAL CLAIM FORM TO:
GHI
P.O. Box 2838
New York, NY 10116-2838
PART A: SUBSCRIBER INFORMATION
PART B: PATIENT INFORMATION
1. SUBSCRIBER’S CERTIFICATE NUMBER CATEGORY GROUP
1. PATIENT’S FIRST NAME
2. PATIENT’S DATE OF BIRTH
MONTH
DAY
YEAR
2. SUBSCRIBER’S NAME AND ADDRESS
3. PATIENT’S RELATIONSHIP TO SUBSCRIBER
4. SEX
LAST
FIRST
MALE
SUBSCRIBER
SPOUSE
SON
DAUGHTER
OTHER: SPECIFY
1
2
3
4
NO. AND STREET
APT. NO.
FEMALE
IS PATIENT A DISABLED DEPENDENT OVER AGE 19?
YES
NO
If Yes, see H on reverse.
YES
NO
5. IS PATIENT A DEPENDENT STUDENT AGE 19 OR OVER? IF YES,
CITY
STATE
ZIP CODE
PART G (DEPENDENT STUDENT INFORMATION) ON THE REVERSE
SIDE MUST BE COMPLETED.
6a. WAS CONDITION RELATED TO PATIENT’S EMPLOYMENT?
AREA CODE
TELEPHONE NUMBER
6b. WAS CONDITION RELATED TO AN AUTO ACCIDENT?
(
)
6c. WAS CONDITION RELATED TO OTHER ACCIDENT?
3a. IS THE SUBSCRIBER’S
3b. DOES THE SUBSCRIBER OR SPOUSE HAVE
YES
YES
Any person who knowingly and with intent to defraud any insurance company or
SPOUSE EMPLOYED?
ADDITIONAL DENTAL INSURANCE COVERAGE?
other person files an application for insurance or statement of claim concerning any
NO
NO
materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is
IF YOU ANSWERED YES TO EITHER QUESTION 3a. OR 3b.,
a crime, and shall also be subject to a civil penalty not to exceed five thousand
PART F (OTHER INSURANCE COVERAGE) ON REVERSE SIDE MUST BE COMPLETED.
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,
PART C: PREDETERMINATION OF BENEFITS
OF ANY INFORMATION NECESSARY TO PROCESS THIS CLAIM. I ALSO CERTIFY THAT BENEFITS
ARE NOT AVAILABLE UNDER ANY OTHER GROUP PLAN EXCEPT AS INDICATED ABOVE.
Your contract may require that a predetermination of benefits be made by GHI prior to
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
appropriate, and mail to GHI. GHI will notify the dentist and subscriber of the amount of
PATIENT’S OR AUTHORIZED SIGNATURE (Parent or Legal Guardian)
DATE
benefits available.
PART D: DENTIST INFORMATION
1. DENTIST NAME
5. IF PROSTHESIS
(IF NO, REASON FOR REPLACEMENT)
DATE OF PRIOR
AND/OR CROWN,
PLACEMENT
YES
IS THIS INITIAL
MAILING ADDRESS
NO
PLACEMENT?
6. IS THIS TREATMENT
IF SERVICES
DATE APPLIANCES PLACED: MOS. TREATMENT
FOR ORTHODONTICS?
ALREADY
REMAINING
YES
CITY, STATE, ZIP CODE
COMMENCED
NO
ENTER:
2. DENTIST TAX IDENTIFICATION NO.
DENTIST LICENSE NO.
I AM A SPECIALIST IN:
ORAL SURGERY
ORTHODONTICS
PERIODONTICS
ENDODONTICS
OTHER
3. FIRST VISIT DATE
PLACE OF TREATMENT
RADIOGRAPHICS OR
NO
YES
HOW
7. CHECK ONLY ONE
CURRENT SERIES
OFFICE, HOSP. OR OTHER
MODEL ENCLOSED?
MANY?
DENTIST’S STATEMENT OF ACTUAL SERVICES: I hereby certify that the
procedures below were rendered and completed on the dates indicated.
DENTIST’S TREATMENT PLAN (PRE-DETERMINATION OF BENEFITS).
4. PARTICIPATING
TO BE COMPLETED BY A PARTICIPATING DENTIST ONLY:
YES (AMOUNT PAID)$
DENTIST IN A GHI PLAN
I HAVE BEEN PAID
YES
NO
NO
SIGNED (DENTIST)
DATE
I WAS NOTIFIED BEFORE SERVICES WERE RENDERED THAT GHI INSURES THE PATIENT.
8. EXAMINATION AND TREATMENT PLAN. LIST IN ORDER FROM TOOTH NO 1 THROUGH TOOTH NO. 32
TOOTH #
DATE SERVICE
ADA
DESCRIPTION OF SERVICE
IDENTIFY MISSING
ADMINISTRATIVE
OR
SURFACE
PERFORMED
PROCEDURE
FEE
(INCLUDING X-RAYS, PROPHYLAXIS,
TEETH WITH “X”
USE ONLY
LETTER
MO
DAY
YEAR
CODE
MATERIALS USED, ETC.)
TOTAL
FEE
CHARGED
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