Various Fillable Forms
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 MoreJ400 (Same as ADA Dental Claim Form – J401, J402, J403, J404). To Reorder call 1-800-947-4746 ... Date of Birth (MM/DD/CCYY). 23. Patient ID/Account ... Less
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