Attending Dentist'S Statement Form
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1CLAIM FORM
FOR DDKS USE ONLY
ATTENDING DENTIST’S STATEMENT
CHECK ONE:
FOR PREDETERMINATION
Delta Dental of Kansas
FOR PAYMENT
P.O. Box 789769
Wichita, KS 67278-9769
1. PATIENT NAME
2. RELATIONSHIP TO PATIENT
3. SEX
4. PATIENT BIRTH DATE
5. IF FULL-TIME STUDENT OVER AGE 19
FIRST
MIDDLE
LAST
M
MM
DD
YY
F
SCHOOL
CITY
SELF
CHILD
P
SPOUSE
OTHER _________
A
6. EMPLOYEE/SUBSCRIBER NAME AND MAILING ADDRESS
7. EMPLOYEE/SUBSCRIBER
8. EMPLOYEE/SUBSCRIBER
9. EMPLOYER (COMPANY)
T
MEMBER NUMBER
BIRTH DATE
I
E
10. GROUP NUMBER
N
T
13B. EMPLOYEE/SUBSCRIBER
13D. RELATIONSHIP TO PATIENT
12. IS PATIENT COVERED BY ANOTHER
13A. EMPLOYEE/SUBSCRIBER NAME
13C. EMPLOYEE/SUBSCRIBER
DENTAL PLAN (IF YES, COMPLETE 13-15)
MEMBER NUMBER
BIRTH DATE
(IF DIFFERENT THAN PATIENT’S)
S
SELF
PARENT
YES
NO
IS PATIENT COVERED BY A MEDICAL PLAN?
E
SPOUSE
OTHER ________
YES
NO
15B. GROUP NO (S)
C
14. NAME AND ADDRESS OF EMPLOYER
15A. NAME AND ADDRESS OF CARRIER (S)
T
15C. AMOUNT PAID BY OTHER INSURANCE
I
O
I HEREBY ACCEPT THE FOREGOING TREATMENT PLAN AND AUTHORIZE RELEASE OF ANY INFORMATION RELATING TO THIS CLAIM. I UNDERSTAND THAT THE PORTION OF THE DENTIST’S CHARGES COVERED UNDER THE DENTAL CARE
N
PLAN NAMED ABOVE WILL BE PAID DIRECTLY TO THE DENTIST, UNLESS THE DENTIST IS NOT A PARTICIPATING DENTIST WITH DELTA DENTAL OF KANSAS IN WHICH CASE PAYMENT WILL BE MADE DIRECTLY TO THE SUBSCRIBER.
PATIENT (PARENT OR
X
EMPLOYEE) SIGNATURE
__________________________________________________________________________________________________________________________________________________________ DATE _____________________________________
DENTIST PHONE NO.
NO
YES IF YES, ENTER BRIEF DESCRIPTION AND DATES
16. DENTIST NAME OR BUSINESS NAME
24. IS TREATMENT
D
RESULT OF
E
OCCUPATIONAL
N
ILLNESS OR INJURY?
17. MAILING ADDRESS
25. IS TREATMENT
T
RESULT OF AUTO
I
ACCIDENT?
S
T
CITY, STATE, ZIP
26. OTHER ACCIDENT?
S
E
18. DENTIST SOC. SEC. OR T.I.N.
19. DENTIST LICENSE NO.
20. DENTIST NPI NO.
28. IF PROSTHESIS,
(IF NO, REASON FOR REPLACEMENT)
29. DATE OF PRIOR
C
PLACEMENT
IS THIS INITIAL
T
PLACEMENT?
I
O
21. FIRST VISIT DATE
22. PLACE OF TREATMENT
23. X-RAYS, PHOTOS,
NO YES HOW
30. IS TREATMENT
DATE APPLIANCES PLACED
IF SERVICES
MOS. TREATMENT
MANY?
REMAINING
ALREADY
HOSP
ECF
OTHER
CURRENT DATE
OFFICE
MODELS ENCLOSED?
FOR
N
COMMENCE
ORTHODONTICS?
ENTER
35.
36.
37.
32.
33.
34.
35.
36.
37.
32.
33.
34.
IDENTIFY MISSING
PROC
DATE
FEE
TOOTH
ARCH
DESCRIPTION OF SERVICE
DATE
PROC
FEE
TOOTH
ARCH
DESCRIPTION OF SERVICE
TEETH WITH “X”
SERVICE COMPLETED
CODE
# OR
SURFACE
# OR
SURFACE
SERVICE COMPLETED
CODE
MO. DAY YEAR
LETTER
OR QUAD
LETTER
OR QUAD
MO. DAY YEAR
21
0120
Amalgam
Periodic Oral Evaluation
FACIAL
21
0140
Amalgam
Ltd. Oral Eval.-Problem Focused
0150
21
8
9
Amalgam
Comprehensive Oral Evaluation
7
10
6
11
0160
5
23
12
Composite - Resin
Detailed Oral Eval.-Problem Focused
4
E F
13
D
G
0210
23
3
14
Complete series-radiographic images
Composite - Resin
C
H
2
B
I
15
0220
23
1st P.A. radiographic image
Composite - Resin
LINGUAL
1
16
A
J
0230
3310
R.C.T. Anterior
(
) Add’l P.A. radiographic image
0270
3320
Bitewing - 1 Radiographic Image
R.C.T. Bicuspid
LEFT
RIGHT
0272
3330
Bitewings - 2 Radiographic Images
R.C.T. Molar
434
0273
Root Planing/Scaling
Bitewings - 3 Radiographic Images
T
K
32
17
0274
434
LINGUAL
Bitewings - 4 Radiographic Images
Root Planing/Scaling
S
L
31
18
R
M
0330
4910
Perio Maintenance
30
Panoramic
Q
19
P O N
29
20
1110
7140
Adult Prophy
Extraction
21
28
22
27
23
26
1120
7140
Extraction
25
24
Child Prophy (through age 13)
12
Fluoride application
FACIAL
TOTAL
38. REMARKS FOR UNUSUAL SERVICES
FEE
CHARGED
39.
I HEREBY CERTIFY THAT THE PROCEDURES, AS INDICATED BY DATE, HAVE BEEN COMPLETED BY ME AND WERE NECESSARY IN MY PROFESSIONAL JUDGMENT AND THAT THE FEE SHOWN IS MY USUAL FEE
AND THE FEE I INTEND TO COLLECT EXCEPT WHERE NOTED. I REQUEST PAYMENT IN ACCORDANCE WITH DDKS RULES AND REGULATIONS.
X _______________________________________________________________________________________________
______________________________
_________________________________________
_________________
SIGNED (TREATING DENTIST)
LICENSE NUMBER
NPI NUMBER
DATE
ADDRESS WHERE TREATMENT WAS PERFORMED, IF DIFFERENT THAN MAILING ADDRESS.
40.
_________________________________________________________________________________________________
_________________________________________
____________________
__________________________
ADDRESS
CITY
STATE
ZIP
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