Dental Reimbursement Claim Form - Decatur County Board Of Education printable pdf download

Decatur County Board of Education

Dental Reimbursement Claim Form

Please submit this form with a paid cash receipt, charge card receipt, or a cancelled check attached. Reimbursements

cannot and will not be made unless this form is completed and signed with proper documentation attached

Claim Forms submitted to DCBOE by 4:30 Monday will be paid out on Thursday

Section I TO BE COMPLETED BY EMPLOYEE

(please complete all information)

Employee’s Name: ____________________________________________________ Employee’s SS#:_________/_________/__________

Employee’s Work Location: ________________________________________________

Work Phone: _________-_________-________

Home Address: _________________________________________________________________________________________

City: ______________________________ State: _______ Zip: ___________ Employee’s Home Phone:_________-_________-_________

Section II TO BE COMPLETED BY EMPLOYEE

(please complete all information)

Patient’s name

Patient’s SS#:

: ________________________________________________________________________

_________/_________/__________

***Patient’s date of birth (claim will not be processed without this)

_________/_________/__________

All dependents who are over 19 years old MUST be a full time student to receive dental benefits; forms will be returned unprocessed if

proper documentation as a full-time student has not been received.

Patient’s Relationship to Employee:

Self

Spouse

Dependent

Amount of Dental Expenses incurred: $_____________________

Notes: _______________________________________________

EMPLOYEE STATEMENT

I certify that the charges for which I am requesting reimbursement have been paid in full and were made during the current reimbursement period. False

receipts and forgery will be considered as a fraudulent act and will be grounds for dismissal. I also authorize my dentist to send the Decatur County Board

of Education copies of records on any claim made if requested.

Employee’s Signature: _____________________________________________

Date:____________________________

HIPPA: This form is used to authorize, The DCBOE, and its agents, or employees, to use or disclose your protected Health Information (PHI) to the

administrator, or employee’s to administrate our DR Dental Plan. We will use your information for service, billing questions, claims, letters, and to

provide your benefits to you. This authorization is at the request of the individual and will expire as of your termination of employment with the DCBOE.

You have the right to revoke this authorization at any time by giving written notice of my revocation to the County Office. I understand that revocation

of this authorization will not affect any action you took in reliance on this authorization before you received my written notice of revocation. I have had

full opportunity to read and consider the contents of this authorization, and I understand that by signing this form, I am confirming my authorization of

the use/or disclosure of my protected health information as described in this form.

Section III TO BE COMPLETED BY DENTIST

Date

Dental Procedure Performed

Normal

Total Amount

Service

Patient’s Name

or attach statement of

Discount

Charge

Paid