Dental Claim Form printable pdf download

Dental Claim Form

Instructions

Fax completed form to 1-855-400-9307

Questions? 1-888-729-5433, Ext. 2013

Mon. – Fri. 7:30 am to 8:30 pm

Sat. 9:00 am to 3:00 pm (CST)

Missing or inaccurate information on claim forms will cause delays in claim processing. The

following blocks are required for reimbursement:

Part I. Information Provided by Employee:

Pretreatment Estimate of Benefits

Block 1 — Patient’s name (the person who received services)

Block 2 — Patient’s relationship to the insured

A Pretreatment Estimate of Benefits lets you

Block 3 — Patient’s gender

know in advance what your benefits will be.

Block 4 — Patient’s date of birth

Before signing a course of treatment, have

Block 5 — Insured’s name (the insured) and date of birth

your dentist estimate the charges and submit

Block 6 — Insured’s Social Security Number

for a pretreatment estimate. This will

Block 7 — Insured’s mailing address

eliminate misunderstanding and let both you

Block 8 — Complete only if the dependent if over the age of 19

and your dentist know what the plan will pay.

Block 9 — Employer’s information

If your dental coverage terminates for any

Block 10 — Group number

reason

during

treatment,

only

the

Block 11 — Provide information only if the patient is covered by another insurance carrier

procedures performed before the dental

Left signature line must be signed

coverage terminated will be eligible for

b. Right signature line is signed only if the reimbursement goes to the provider

payment. We suggest you read the complete

(leave blank if the reimbursement goes to the insured)

certificate and become acquainted with the

benefits offered by your dental insurance.

Actual payment will be based on available

benefits at time of claims payment

Part II. Information Provided by Dentist:

We recommend a pretreatment estimate if

Block 12 & Block 13 — Provider’s name and mailing address

your dental work will cost $300 or more.

Block 14 — Provider’s Federal Tax ID Number

Block 16 — Provider’s telephone number

* Proof of Payment is required for reimbursement. A copy of a bill or statement can be attached with the claim form, if

it includes type of services rendered, when the services were performed and the charged amounts.

Part III: You may submit your Dental Claim form in the following ways:

Mail:

Email:

AlwaysCare Dental

P.O. Box 80139

Baton Rouge, LA 70898-4389

Fax:

Electronic Payer ID:

Local: (225) 400-9307

STR01

Toll Free: (855) 400-9307

DCFI1111

Dental Claim Form

Related Articles

Related forms

Related Categories