Dental Claim Form - Blue Shield Of California printable pdf download

DENTAL CLAIM FORM

Blue Shield of California

Submit Dental Claims To: Blue Shield, P.O. Box 272590, Chico, CA 95927-2590

Question? Call: 1 (877) 403-2273, Monday through Friday, 5 a.m. to 8 p.m., PT

Blue Shield Use Only

IMPORTANT: Treatment plans exceeding $1,200.00 should be submitted

for precertification. Failure to do so may result in patient responsibility

for claims subsequently adjusted or denied.

Patient/participant information

1. Patient Name

2. Relationship To Employee

3. Sex

4. Patient Birthdate

5. If Full Time Student

Self Spouse/Domestic Partner Child Other

Month

Day

Year

School

City

6. Employee/

First

Initial

Last

7. Employee/participant No.

(see dental ID card)

Subscriber Name

8. Mailing Address,

9 . Group Name

Street, City, State,

County of Orange

Zip Code

10. Is patient covered by

Dental Plan Name

Union Local

Policy No.

Name and Address of Carrier

another dental plan?

Dentist information

c Dentist's pretreatment estimate

c Dentist's statement of actual services

11. Dentist SS# or T.I.N.

12. Dentist license no. 13. Dentist phone no. 14. Dentist's name, address, city, state, Zip Code

15. Provider ID

16. First visit date of

17. Place of treatment

18. Radiographs or

22. If Prosthesis/

If No, the reason for

23. Date of prior

Yes

current series

Office

Hospital

ECF

Other

models enclosed?

crown is this ini-

replacement

placement

tial placement?

Yes

How many?

19. Is treatment result of

If yes, enter brief description

24. Is treatment

If services already commenced enter:

Yes

occupation illness or

and dates

for orthodontics?

Date appliances placed

Months of treatment remaining

injury?

20. Is treatment result of

I hereby certify that the services listed have been or will be provided by me.

Yes

auto accident?

Dentist’s Signature

Date

21. Other accident?

Yes

25. Examination and treatment plan

List in order from tooth no. 1 Through tooth no. 32

Blue

Shield

use only

Identify missing teeth with "X"

Tooth

Surface

Description of Service

Date Service

ADA

Fee

FACIAL

No. or

(Including x-rays, prophylaxis, materials used etc.)

Performed

Procedure

Allowed

letter

Number

Amount

DAY

YEAR

8 9 10

6 7

D E F G

LINGUAL

RIGHT

LEFT

LINGUAL

Q P O N

Total Fee

Actually Charged

FACIAL

Remarks:

26. Patients Authorization:

I have been informed of the treatement plan and associated fees identified above, and, to the extent permitted by law, I authorize the

release of information relative to this course of treatment and to the payment activities in connection with this claim.

I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or

dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. I understand that I am responsible for the charges for

any service not approved by benefit pre-certification review, or are rendered during any ineligible period and for the copayments, deductibles and amounts

exceeding the calendar year maximum of my dental plan. I understand that I may request a copy of any precertification review determination from Blue Shield.

Signed (Patient or Guardian if Minor)

Date

27.

I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the above named dentist or dental entity.

Participant/Member Signature

Date