Form Del7014521 - Claim Form

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HEADER 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
OTHER COVERAGE
3. Name, Address, City, State, Zip Code
16. Other Dental or Medical Coverage?
No (Skip 17-23)
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)
5. Date of Birth (MM/DD/CCYY)
6. Gender
7. Subscriber Identifier (SSN or ID#)
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
21. Plan/Group Number
22. Relationship to Primary Subscriber (Check applicable box)
PATIENT INFORMATION
Self
Spouse
Dependent
Other
10. Relationship to Primary Subscriber (Check applicable box)
11. Student Status
Self
Spouse
Dependent Child
Other
FTS
PTS
23. Other Carrier Name, Address, City, State, Zip Code
12. Name (Last, First, Middle Initial, Suffix), 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
24. Procedure Date
25. Area
26.
27. Tooth Number(s)
28. Tooth
29. Procedure
(MM/DD/CCYY)
of Oral
Tooth
or Letter(s)
Surface
Code
30. Description
31. Fee
Cavity
System
1
2
3
4
5
6
7
8
9
10
MISSING TEETH INFORMATION
32. Other
Permanent
Primary
Fee(s)
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
34. (Place an ‘X’ on each missing tooth)
33. Total Fee
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
35. Remarks
AUTHORIZATIONS
ANCILLARY CLAIM/TREATMENT INFORMATION
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)
39. Number of Enclosures (00 to 99)
charges for dental services and materials not paid by my dental benefit plan, unless prohibited by
Radiograph(s) Oral Image(s) Model(s)
law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all
Provider’s Office
Hospital
ECF
Other
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.
40. Is Treatment for Orthodontics?
41. Date Appliance Placed (MM/DD/CCYY)
No (Skip 41-42)
Yes (Complete 41-42)
X________________________________________________________________________________
Patient/Guardian signature
Date
42. Months of Treatment 43. Replacement of Prostheses? 44. Date Prior Placement (MM/DD/CCYY)
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________________________________________________________________________________
Subscriber signature
Date
46. Date of Accident (MM/DD/CCYY)
47. Auto Accident State
BILLING DENTIST OR DENTAL ENTITY
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
(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
48. Name, Address, City, State, Zip Code
charged and intend to collect for those procedures.
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
52. Phone Number (
)
57. Phone Number (
)
58. Treating Provider
Specialty
DEL7014521 (11/08)

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