Dental Plan Claim Form - Delta Dental Of Wisconsin
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1Dental Plan Claim Form
Delta Dental of Wisconsin
Policyholder
Patient
1. Policyholder SSN/ID#
2. Birth Date
3. Gender
9. Patient Name (Last, First, M.I., Suffix)
10. Gender
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-
4. Policyholder Name (Last, First, M.I., Suffix)
11. Relationship to Policyholder
12. Birth Date
13. Student
-
-
5. Policyholder Address
I have been informed of the treatment plan and associated fees. I agree to be
responsible for charges for dental services and materials not paid by my dental benefit
6. Policyholder City, State, Zip
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. To
the extent permitted by law, I consent to your use and disclosure of my protected
7. Policyholder Employer
8. Plan/Group #
health information to carry out payment activities in connection with this claim.
I hearby authorize and direct payment of the dental benefits otherwise payable to me,
directly to the named dentist or dental entity.
Signed:
Date:
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-
Signed:
Date:
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-
Parent or Guardian
Insurance Information
14. Primary Insurance Company
15. Primary Insurance Address, City, State, Zip
16. Primary Insurance Payment
17. Transaction Type:
Statement of Service
Request for Predetermination/Preauthorization
Other Coverage
18. Secondary Coverage:
19. Name of Policyholder (Last, First, M.I., Suffix)
Yes
No
If Yes:
Dental
Medical
20. Relationship to Policyholder
21. Birth Date
22. Gender
23. Covered SSN/ID#
24. Plan/Group #
-
-
25. Secondary Insurance Company
26. Predetermination/Preauthorization Number
27. Secondary Insurance Address, City, State, Zip
Ancillary Information
28. Place of Treatment (circle):
Provider's Office
Hospital
ECF
29. Number of enclosures (0 to 99):
Radiograph(s):
Oral Image(s):
Model(s):
Charting:
31. Prior Placement Date
30. Prosthesis Placed:
Initial Placement
Prior Placement
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-
33. Accident Date
34. Accident State
32. Treatment resulting from:
Occupational Injury/Illness
Auto Accident
Other Accident
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-
36. Placed Date
37. Months Remaining
35. Treatment for Orthodontics
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-
Provider Information
I hearby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed.
Dentist Signature:
Date:
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-
38. Treating Provider Name (Last, First, M.I., Suffix)
39. Phone
40. Treating Provider Address, City, State, Zip
41. Taxonomy Code
42. Provider NPI# (Type 1)
43. License #/Other ID
44. Provider Billing NPI# (Type 2)
45. License #/Other ID
46. Provider Billing Name (Last, First, M.I., Suffix)
47. Provider Billing SSN/TIN#
48. Phone
49. Provider Billing Address, City, State, Zip
Services
50. Check missing
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15
16
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
32
tooth number(s)
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
51. Procedure
52. Oral
53. Tooth
54. Tooth
55. Diagnostic Codes
56. Procedure
57. Treatment
58. Fee
Date
Cavity
#/Letter
Surface
Code
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
59. Remarks
60. Total Fee
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