Dental Insurance Claim Form Metlife
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1
2Metropolitan Life Insurance Company
Dental Expense Claim Form
(Please Read Instructions on Reverse Side before Completing this Form)
1. Patient First Name
Middle
Last
2. Relationship to Employee
3. Sex
4. Married 5. Patient Date of Birth
6. For Office Use
Self
Spouse Child
Other
M F
Yes No
Mo
Day
Year
7. If Full Time Student (Age 19 or Over)
City
State
8. EMPLOYEE SOC. SEC. NO.
9. If Disabled
10. Name of Group Dental Program
School
(Age 19 or Over)
Yes
No
11. Employee First Name
Middle
Last
12. Employee Date of Birth
13. Office Phone (area code)
14. Employee Residence Mailing Address
15. City, State, Zip
16. Are other Family Members Employed?
Yes
No
17. Date of Birth 18. Name and Address of Employer for Item 16
Name
Soc. Sec. No.
19. Is Patient Covered by
(If Yes, Complete the Following)
Dental Plan Name
Group No.
Name and Address of Carrier
Another Dental Plan?
Yes
No
20. I Authorize Release of any Information Relating to this Claim
21. I Authorize Payment Directly to the Below Named Dentist.
Signed (Patient, or Parent if Minor)
Date
Employee Signature
Date
22. I declare that the above information is correct.
If you are covered under a self-insured plan or insured under a policy issued in any state other than those listed below, or if you reside in any state other than those listed
below, then the following warning may apply to you:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any
materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a
crime and subjects such person to criminal and civil penalties.
If you are insured under a policy issued in one of the following states, or if you reside in one of the following states, one of the following state warnings may apply to you:
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Florida:
Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim containing any false, incomplete or misleading
information is guilty of a felony of the third degree.
Virginia:
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, files a claim containing a false or deceptive statement may
have violated state law.
New York:
I know it is a crime to fill out this form with facts I know are false or to leave out facts I know are important. I know that if I do this, I may also have to pay a civil
penalty of up to $5,000 plus the value of the claim.
Employee Signature
Date
23. Dentist Name
31. Is Treatment Result
No Yes
If Yes, Enter Brief Description and Dates
of Occupational
Illness or Injury?
24. Mailing Address
32. Is Treatment Result
of Auto Accident?
33. Other Accident?
City, State, Zip
34. Are any Services
Covered by
Another Plan?
25. Dentist Soc. Sec. No. or T.I.N. 26. Dentist License No. 27. Dentist Phone No.
35. If Prosthesis, is
(If No, Reason For Replacement)
36. Date of Prior
this Initial
Placement
Placement?
28. First Visit Date
29. Place of Treatment 30.Radiographs or
No Yes
How 37. Is Treatment for
If Services
Date Appliance Placed
Mos. Treatment
Already
Current Series
Models Enclosed?
Many?
Orthodontics?
Remaining
Office Hosp ECF Other
Commenced,
Enter
Dentist's
38. Examination and Treatment Plan-List in Order From Tooth No. 1 Thro ugh Tooth No. 32
Use Charting System Shown
Pre-Treatment Estimate
Statement of Actual
Tooth
Surface
Description of Services (Including X-Rays,
Date
ADA
Fee
For
Services
# or
Prophylaxis, Materials Used, Etc.)
Service
Procedure
Carrier
Letter
Line No.
Performed
Number
Use Only
*(Be Sure To Sign Below)
Mo. Day Yr.
FACIAL
Total Fee
39. I Hereby Certify That The Services Listed Above
Will Be
Have Been Performed.
Actually
Charged
Date
*Signed (Dentist)
40. Address where treatment was performed.
FACIAL
INDICATE MISSING TEETH
Street
City
State
Zip Code
WITH AN "X"
JY0333.SCRE(06/01)
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