Form Del7014521 - Delta Dental Claim Form
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1HEADER INFORMATION
CARRIER NAME AND ADDRESS:
2. Delta Dental of Illinois
1. Type of Transaction (Check all applicable boxes)
P.O. Box
5402
Statement of Actual Services – OR –
Request for Predetermination / Preauthorization
Lisle, IL 60532
(Please do not use for DeltaCare dental HMO)
PRIMARY PAYER INFORMATION
3. Name, Address, City, State, Zip Code
OTHER COVERAGE
16. Other Dental or Medical Coverage?
No (Skip 1 -23)
7
Yes (Complete 16-23)
PRIMARY SUBSCRIBER INFORMATION
4. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
17. Subscriber Name (Last, First, Middle Initial, Suffix)
6. Gender
7. Subscriber Identifier (SSN or ID#)
5. Date of Birth (MM/DD/CCYY)
M
F
18. Date of Birth (MM/DD/CCYY)
19. Gender
20. Subscriber Identifier (SSN or ID#)
8. Plan/Group Number
9. Employer Name
M
F
PATIENT INFORMATION
22. Relationship to Primary Subscriber (Check applicable box)
21. Plan/Group Number
10. Relationship to Primary Subscriber (Check applicable box)
11. Student Status
Self
Spouse
Dependent
Other
Self
Spouse
Dependent Child
Other
FTS
PTS
12. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
23. Other Carrier Name, Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY)
14. Gender
15. Patient ID/Account # (Assigned by Dentist)
M
F
RECORD OF SERVICES PROVIDED
25. Area
26.
24. Procedure Date
27. Tooth Number(s)
28. Tooth
29. Procedure
of Oral
Tooth
30. Description
31. Fee
or Letter(s)
(MM/DD/CCYY)
Surface
Code
Cavity
System
1
2
3
4
5
6
7
8
9
10
MISSING TEETH INFORMATION
Permanent
Primary
32. Other
Fee(s)
1
2
3
4
5
6
7
8
9
10
1 1
1 2
13
14
15
16
A
B
C
D
E
F
G
H
I
J
34. (Place an 'X' on each missing tooth)
24
23
22
21
20
19
18
17
T
S
R
Q
P
33.Total Fee
32
31
30
29
28
27
26
25
O
N
M
L
K
35. Remarks
AUTHORIZATIONS
ANCILLARY CLAIM/TREATMENT INFORMATION
39. Number of Enclosures (00 to 99)
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all
38. Place of Treatment (Check applicable box)
Radiograph(s)
Oral Image(s)
Model(s)
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
Provider’s Office
Hospital
ECF
Other
such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health
40. Is Treatment for Orthodontics?
41. Date Appliance Placed (MM/DD/CCYY)
information to carry out payment activities in connection with this claim.
No (Skip 41-42)
Yes (Complete 41-42)
X
42. Months of Treatment
43. Replacement of Prosthesis?
44. Date Prior Placement (MM/DD/CCYY)
Patient /Guardian signature
Date
Remaining
No
Yes (Complete 44)
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named
dentist or dental entity.
45. Treatment Resulting from (Check applicable box)
Occupational illness / injury
Auto accident
Other accident
X
47. Auto Accident State
Subscriber signature
Date
46. Date of Accident (MM/DD/CCYY)
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
BILLING DENTIST OR DENTAL ENTITY
(Leave blank if dentist or dental entity is not submitting
claim on behalf of the patient or insured/subscriber)
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple
visits) or have been completed and that the fees submitted are the actual fees I have charged and intend to
collect for those procedures.
48. Name, Address, City, State, Zip Code
X
Signed (Treating Dentist)
Date
54. Individual NPI (Type 1)
55. License Number
56. Address, City, State, Zip Code
49.
Corporate
Entity NPI (Type 2)
50. License Number
51. SSN or TIN
58. Treating Provider
52. Phone Number (
)
–
57. Phone Number (
)
–
Specialty
DEL7014521 (11/08)
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