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
Fill & Sign Online, Print, Email, Fax, or Download
You'll be responsible for having your provider complete and sign a claim form.
... the HCFA 1500 Institutional is the UB04 Dental is the 2006 ADA form ...
Results 1 - 10 of 31 ... 9 Accessing and Navigating the Dental Claim Form Accessing the Dental ... .wa.
gov/medicaid/provider/Documents/manual_submittingdentalclaim.pdf ... ADA
Dental Attachments This is used when a paper ADA dental claim ...