Dental Claim Form Page 2
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1
2Group Claim Office
GROUP DENTAL CLAIM FORM
P. O. Box 80139, Baton Rouge, LA 70898-0139
PART 1 – TO BE COMPLETED BY EMPLOYEE
Toll Free No.: 1-888-729-5433 (B.R. 926-2888)
1. Patient’s Full Name (First, Middle Initial, Last)
2. Relationship to Employee
3. Sex
4. Patient Birthdate
Self
Spouse
Child
Other
M
F
Mo.
Day
Year
5. Employee’s Full Name (First, Middle Initial, Last)
Employee’s Birthdate
6. Employee’s Social Security Number
Mo.
Day
Year
8. THIS SECTION MUST BE COMPLETED WITH EACH CLAIM SUBMISSION ONLY IF THE
7. Employee’s Mailing Address (Street, City, Zip)
CLAIM IS FOR A DEPENDENT CHILD AGE 19 OR OVER.
Street or P. O. Box
Is patient a full time student?
Yes
No
If yes, Name of School
City, State, Zip
Address of School
9. Employee’s Company Name and Address
10. Group No.
Div. No.
Cert. No.
QUESTION 11. MUST BE COMPLETED WITH EACH CLAIM SUBMISSION
11. Is patient covered by another dental plan?
Yes
No
If yes, Employer/Plan Name____________________________Policy Number
Name and Address of Insurance Carrier
If yes, please complete below:
Name of Insured:
Relationship
Date of Birth
Social Security Number
Name and Address of Employer:
Mo.
Day
Year
Spouse
Child
I
I hereby authorize payment direct to the below named dentist of the group
have reviewed the treatment plan, and I authorize release of any information relating to
this claim. I understand I am responsible for all cost of dental treatment. I certify these
insurance benefits otherwise payable to me.
statements to be true and complete to the best of my knowledge. I understand that any
person who knowingly and with intent to injure, defraud or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading
information is guilty of a felony. All work covered on this form has been completed.
____________________________________________ _____/_____/_____
____________________________________________ _____/_____/_____
Signed (Insured Person)
Date
(If signed here, signature also needed in box on left.)
Signed (Patient, or parent if minor)
Date
PART 2 – TO BE COMPLETED BY ATTENDING DENTIST – Please provide ADA Procedure Number to ensure accurate benefit determination.
Name of Patient:
DENTIST – CHECK ONE:
Pretreatment Estimate
Statement of Actual Services
Name of Insured Person:
Has all work been completed? Y____N____
12. Dentist Name and 13. Mailing Address
20. Is treatment result of
No
Yes
If yes, enter brief description and dates.
occupational illness or injury?
21. Is treatment result of Auto
Accident?
22. Other Accident?
23. Are any services covered by
another plan?
14. Dentist Soc. Sec. Or TIN
15. Dentist License
16. Dentist Phone
24. If Prosthesis, is this initial
(If no, reason for replacement) Date of
#
#
placement?
prior placement
17. First Visit
18. Place of Treatment
19. Radiographs or
No
Yes
How
25. Is treatment for
Enter date appliances placed, if
Date Current
Models enclosed?
Many?
Orthodontics?
services already commenced.
Office
Hosp
ECF
Other
Series
____/____/____
Months of treatment remaining:_______
Identify Missing Teeth with “X”
Tooth No.
DESCRIPTION OF SERVICES
ADA Procedure
Date Service Performed
Remarks for unusual services.
or Letter
Surfaces
(including X-rays, Prophylaxis, Materials used, etc.)
Number
Mo.
Day
Yr.
Fee
$
CERTIFICATION: I certify that the services listed above have been completed on the dates indicated and that the fees
TOTAL FEE CHARGED
$
submitted are the fees I have charged and intend to collect for those purposes.
__________________________________________ _____/_____/_____
SIGNED (DENTIST)
DATE
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