MEDICAIDPROVIDER HHS MT
HEADER INFORMATION Dental Claim Form Request for Predetermination / Preauthorization 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services EPSDT/ Title XIX 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 MoreA. The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit plan) is visible in a Less
Not the form you were looking for?
Upload form
Not the form you were looking for?
Upload form
Please wait while form is uploaded and processed.
After you finish filling the form, you can Print, Email or Export your form. |
|