Metlife Dental Claim Form
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1
2Dental Expense Claim
Metropolitan Life Insurance Company
To Be Completed by Employee (You must review the important statements on page 2 and sign where indicated before completing this section of the form.)
1. Patient First Name
Middle
Last
2. Relationship to Employee
3. Sex
4. Married?
5. Patient Date of Birth
6. For Office Use
Mo. / Day / Year
Self
Spouse
Child
Male
Yes
1640340
Other
Female
No
7. If Full Time Student (Age 19 or Over)
8. EMPLOYEE Social Security / ID Number
9. If Disabled
10. Name of Group Dental Program
School
City
State
(Age 19 or Over)
B.O.C.E.S.
Yes
No
13. Office Phone (Area Code)
11. Employee First Name
Middle
Last
12. Employee Date of Birth
14. Employee Residence Mailing Address
15. City, State, Zip
17. Date of Birth
18. Name and Address of Employer for Item 16
16. Are other Family Members Employed?
Yes
No
Name
Social Security / ID Number.
19. Is Patient Covered by Another Dental Plan?
Yes
No
(If Yes, complete the following:)
Dental Plan Name
Group No.
Name and Address of Carrier
20. I Authorize Release of any Information Relating to this Claim
21. I Certify that the Above Information is Correct.
22. I Authorize Payment Directly to the Below Named Dentist.
_______________________________________
_______________
____________________________________
__________________
__________________________________
__________________
(Signature of Patient or signiture of Authorized
Date
Representative if Minor)
Employee Signature
Date
Employee Signature
Date
If Authorized Representative, Relationship to Minor
To Be Completed by Dentist
23. Dentist Name
24. Mailing Address
City
State
Zip
25. Dentist Social Security Number or T.I.N.
26. Dentist License Number
27. Dentist Phone Number
28. First Visit Date Current Series
29. Place of Treatment
30. Radiographs or Models Enclosed?
Office
Hospital
ECF
Other _______________________________________
Yes
No How Many?_____________
31. Is Treatment Result of Occupational Illness or Injury?
Yes
No
32. Is Treatment Result of Auto Accident?
Yes
No
(If Yes, Enter Brief Description and Dates)
(If Yes, Enter Brief Description and Dates)
33. Other Accident?
34. Are any Services Covered by Another Plan?
Yes
No
Yes
No
(If Yes, Enter Brief Description and Dates)
(If Yes, Enter Brief Description and Dates)
35. If Prosthesis, is this Initial Placement?
Yes
No
36. Date of Prior Replacement?
(If No, Reason for Replacement)
37. Is Treatment for Orthodontics?
If Services Already Commenced, Enter Date Appliance Placed
Months of Treatment Remaining
Yes
No
Dentist’s —
Pretreatment Estimate
Statement of Actual Services (Be sure to sign below)*
38. Examination and Treatment Plan – List in Order From Tooth #1 through Tooth #32 (Use Charting System Shown)
Tooth #
Date Service
ADA
Description of Services
For Carrier
or
Surface
Performed
Procedure
Fee
(Including X-Rays, Prophylaxis, Materials Used, Etc.)
Use Only
Letter
Mo. / Day / Year
Number
39. I Hereby Certify That The Services Listed Above
Will Be
Have Been Performed
Total Fee
* Signature of Dentist
Date ___________________
Actually Charged
40. Address where treatment was performed
Street _______________________________________________________________________ City __________________________________ State ______________ Zip _____________________
Page 1 of 2
JY0333 (08/03)
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