Dental Claim Form - Delta Dental
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1Dental Claim Form
HEADER INFORMATION
1. Type of Transaction (Mark all applicable boxes)
Statement of Actual Services
Request for Predetermination/Preauthorization
P.O. Box 9695
Customer Service
Boston, MA 02114
800-872-0500
2. Predetermination/Preauthorization Number
POLICYHOLDER/SUBSCRIBER INFORMATION
(For Insurance Company Named in #3)
12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix) Address, City, State, Zip Code
INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION
3. Company/Plan Name, Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY)
14. Gender
15. Policyholder/Subscriber ID (SSN or ID#)
M
F
16. Plan/Group Number
17. Employer Name
OTHER COVERAGE
4. Other Dental or Medical Coverage?
No (Skip 5-11)
Yes (Complete 5-11)
PATIENT INFORMATION
5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix)
18. Relationship to Policyholder/Subscriber Named in #12 Above
19. Student Status
Self
Spouse
Dependent
Other
FTS
PTS
6. Date of Birth (MM/DD/CCYY)
7. Gender
8. Policyholder/Subscriber ID (SSN or ID#)
20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
M
F
9. Plan/Group Number
10. Patient’s Relationship to Person Named in #5
Self
Spouse
Dependent
Other
11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State. Zip Code
21. Date of Birth (MM/DD/CCYY)
22. Gender
23. Patient ID/Account # (Assigned by Dentist)
M
F
RECORD OF SERVICES PROVIDED
25. Area
26.
24. Procedure Date
27. Tooth Number(s)
28. Tooth
29. Procedure
30. Description
31. Fee
of Oral
Tooth
(MM/DD/CCYY)
or Letter(s)
Surface
Code
Cavity
System
1
2
3
4
5
6
7
8
9
10
11
32. Other
Fee(s)
12
33. Total Fee
13
34. Remarks
AUTHORIZATIONS
ANCILLARY CLAIM/TREATMENT INFORMATION
38. Number of Enclosures (00-99)
37. Place of Treatment
35. I have been informed of the treatment plan and associated fees. I agree to be responsible for all
charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or
Radiograph(s)
Oral Image(s)
Model(s)
Provider’s Office
Hospital
ECF
Other
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
39. Is Treatment for Orthodontics?
40. Date Appliance Placed (MM/DD/CCYY)
information to carry out payment of activities in connection with this claim.
No (Skip 40-41)
Yes (Compete 40-41)
41. Months of Treatment
43. Date Prior Placement (MM/DD/CCYY)
42. Replacement of Prosthesis?
X
Remaining
Patient/Guardian signature
Date
No
Yes (Complete 43)
36. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the
44. Treatment Resulting from
below named dentist or dental entity.
Occupational illness/injury
Auto accident
Other accident
X
45. Date of Accident (MM/DD/CCYY)
46. Auto Accident State
Subscriber signature
Date
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)
52. I hereby certify that the procedures as indicated by date are in progress (for procedures that
require multiple visits) or have been completed.
47. Name, Address, City, State, Zip Code
X
Signed (Treating Dentist)
Date
53. NPI
54. License Number
55. Address, City, State, Zip Code
56. Provider
Specialty Code
48. NPI
49. License Number
50. SSN or TIN
51. Phone
51A. Additional
57. Phone
58. Additional
(
)
-
(
)
-
Number
Provider ID
Number
Provider ID
To reorder call Grossman Marketing
Group at 1-800-368-1368
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Parent category: Medical