Enterprise Claim Form - Delta Dental - 2011
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1
2Delta Dental Insurance Company
PO Box 1809
TRANSACTION AND PREDETERMINATION INFORMATION
Alpharetta, GA 30023-1809
800-521-2651
13. Type of Transaction (Mark all Applicable Boxes)
Statement of Actual Services
Request for Predetermination/Pre-treatment Estimate
Encounter
EPSDT/ Title XIX
SUBSCRIBER INFORMATION
1. Policyholder / Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code
14. Predetermination/
Pre-treatment
Estimate Number
TREATMENT INFORMATION
15. Treatment Resulting From
Occupational Illness/injury
Auto accident
Other accident
16. Date of Accident (MMDDCCYY)
17. Auto Accident State
2. Date of Birth
(MMDDCCYY)
3. Gender
4. Policyholder / Subscriber ID (SSN or ID#)
18. Place of Treatment
19. Number of Enclosures (00 to 99)
Radiograph(s)
Oral Image(s)
Model(s)
F
M
Provider's Office
Hospital
ECF
Other
5. Plan or Group
6. Employer
20. Is Treatment for Orthodontics?
21. Date Appliance Placed (MMDDCCYY)
Number
Name
No (Skip 21-22)
Yes (Complete 21-22)
PATIENT INFORMATION
22. Months of
23. Replacement of Prosthesis?
24. Date of Prior Placement (MMDDCCYY)
7. Relationship to Policyholder/Subscriber in #1 Above
Treatment
No
Yes (Complete 44)
Remaining
Self
Spouse
Dependent Child
Other
OTHER INSURANCE COVERAGE
8. Patient Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code
25. Other Coverage?
Dental (Complete 26-32)
Medical (Complete 26-32)
None
26. Name of Other Coverage Policyholder / Subscriber (Last, First, Middle Initial, Suffix)
27. Date of Birth (MMDDCCYY)
28. Gender
29. Policyholder / Subscriber ID (SSN or ID#)
M
F
9. Date of Birth (MMDDCCYY)
10. Gender
11. Patient ID/Account # (Assigned by Dentist)
31. Patient's Relationship to Person Named in #26
30. Plan or
Group
M
F
Self
Spouse
Dependent
Other
Number
12. Remarks
32. Other Insurance Company / Dental Benefit Plan Name, Address, City, State, ZIP Code
33. Diagnosis Codes
D.
A.
B.
C.
RECORD OF SERVICES PROVIDED
40. Diagnosis
35. Area of
37. Tooth
38. Quantity
39. Procedure
34. Procedure Date
36. Tooth Number(s)
Pointer
41. Description
42. Fee
Oral Cavity
Surface
Code
(MMDDCCYY)
or Letter(s)
(A, B, etc.)
1
2
3
4
5
6
7
8
Permanent
Primary
MISSING TEETH INFORMATION
43. Total
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
A
B
C
D
E
F
G
H
I
J
Fee
0.00
44. (Place an 'X' on each missing tooth)
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
T
S
R
Q
P
O
N
M
L
K
AUTHORIZATION - RELEASE OF INFORMATION
AUTHORIZATION - ASSIGNMENT OF BENEFITS
45. I have been informed of the treatment plan and associated fees. I agree to be responsible for all
46. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named
charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or
dentist or dental entity
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 health
information to carry out payment activities in connection with this claim.
X
Subscriber signature
Date
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
X
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple
Patient/Guardian signature
Date
visits) or have been completed
BILLING DENTIST OR DENTAL ENTITY
47. Dentist or Entity Name, Address, City, State, ZIP Code
X
Signed (Treating Dentist)
Date
54. Treatment Location Address, City, State, ZIP Code - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
48. NPI
55. NPI
50. SSN
57. Provider
49. License
56. License
or
Specialty
Number
Number
TIN
Code
58. Phone
59. Additional
51. Phone
52. Additional
Number
Provider ID
Provider ID
Number
Delta Dental Enterprise Claim Form
Version 1, Rev 0
10/12/2011
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