Form Ddpi-930 - Delta Dental Claim Form
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1Delta Dental Plan of Illinois
National Dental Programs
1.
Dentist’s pre-treatment estimate
2. Carrier Name and Address
DELTA DENTAL PLAN OF ILLINOIS
Dentist’s statement of actual services
P.O. BOX 5402
LISLE, IL 60532
3. Patient name
4. Relationship to employee
5. Sex
6. Patient birthdate
7. If full time student
first
m.i.
last
m
f
MM
DD
YYYY
school
self
child
city
spouse
other_____________
8. Employee/subscriber name
9. Employee/subscriber dental plan
10.
Employee/subscriber
and mailing address
I.D. number
birthdate
MM
DD
YYYY
11. Employer (company) name
12.
Group number
and address
13. Is patient covered by another
14a.
Name and address of other carrier(s)
14b. Other group no(s)
15. Name and address of other employer(s)
dental plan
yes
no
If yes, complete 14a
Is patient covered by a medical
plan?
yes
no
16a.
Employee/subscriber name
16b. Employee/subscriber
17. Relationship to patient
(if different from patient’s)
birthdate
MM
DD
YYYY
self
child
spouse
other______________
18.
I have reviewed the following treatment plan and fees. I agree to be responsible for all charges for dental
19.
I hereby authorize payment directly to the above-name dentist of the group insurance benefits
services and materials not paid by my dental benefits plan, unless the treating dentist or dental practice has a
otherwise payable to me.
contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted
under applicable law, I authorize release of any information relating to this claim.
_________________________________________________________________
______________________
_________________________________________________________________
____________________
Signed (Parent or guardian)
Date
Signed (Employee/subscriber)
Date
20. Name of Billing Dentist or Dental Entity
29. Is treatment result
No Yes
If yes, enter brief description and dates
of occupational
illness or injury?
21. Address
30. Is treatment result
of auto accident?
22. City, State, Zip
31. Other accident?
23. Dentist Soc. Sec. or TIN
24. Dentist license no.
25. Dentist phone no.
32. If prosthesis, is this
(If no, reason for replacement)
33. Date of prior
initial placement?
placement
26. First visit date
27. Place of treatment
28. Radiographs or
No Yes
How
34. Is treatment for
If service already
Date appliances Mos treatment
current series
Office
Hosp
ECF
Other
models enclosed?
many?
orthodontics?
commenced
placed
remaining
enter
35. Identify missing teeth with “X”
36. Examination and treatment plan - List in order from tooth no 1 through tooth no 32 - Using charting system shown.
For administrative
use only
Tooth #
Description of service
Date service performed Procedure number
Surface
Fee
or letter
(including x-rays, prophylaxis, materials used, etc.)
Mo
Day
Year
37. Remarks for unusual services
38. I hereby certify that the procedures as indicated by date have been completed and that the fees submitted
40. Total Fee
are the actual fees I have charged and intend to collect for those procedures.
Charged
42. Payment by
other plan
_____________________________________________________________________________________________
______________________
Signed (Treating Dentist)
License Number
Date
Max. Allowable
39. Address where treatment was performed
Deductible
City
State
Zip
Carrier %
Carrier pays
Patient pays
DDPI-930 (06/00)
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