THIS CLAIM IS ONLY STATUTORY AND MAY NOT MODIFY, APPLY TO, OR CONSTITUTE AN ADDITION TO ANY OTHER BENEFIT THAT I MAY BE ELIGIBLE FOR. NO SUCH REQUESTS WILL BE ACCEPTED FOR, AND CERTAIN BENEFITS WILL NOT BE AVAILABLE, UNLESS I AM ELIGIBLE FOR SUCH BENEFITS. CHECK WITH YOUR DENTISTRY'S OFFICE BEFORE INVESTIGATING THIS CLAIM. EXCEPT AS SPECIFIED ABOVE, THIS CLAIM IS DISCLAIMED, EXPRESSED, CONSTRUED, AND MODIFIED TO THE EXTENT PERMITTED BY LAW. I UNDERSTAND THAT IF I RECEIVE A CASH TRANSACTION FOR THE PURCHASE OF DENTISTRY SERVICES FROM THIS PLAN I WILL BE GUARANTEED THAT ANY SUCH BENEFITS I AM ELIGIBLE FOR WILL COVER DENTIST'S SERVICES TO EXCEED MY PREMIUM DENTAL INSURANCE. IN THAT CASE, MY COSTS FOR THE DENTAL SERVICES PROVIDED TO ME BY THIS PLAN WILL BE AFFILIATED WITH THE DENTISTRY'S PARTICULAR SERVICES. I AGREE TO TAKE ALL CAUSE FOR ANY COSTS I MAY ACCOUNT MY PARTICULAR SERVICES, WHETHER THEY ARE PROVIDED TO ME BY THIS PLAN OR BY ANOTHER MANUFACTURER. I UNDERSTAND THAT IF THE BENEFITS I ACCEPT UNDER THIS PLAN ARE SUCH THAT I AM ELIGIBLE FOR FULL BENEFITS UNDER ANY INDIVIDUAL HEALTH PLAN WITH PAYOUTS, I WILL NOT BE ELIGIBLE FOR BENEFITS UNDER ANY COVERED HEALTH PLAN WITH PAYOUTS. IF I AM NOT ELIGIBLE FOR BENEFITS UNDER AN INDIVIDUAL HEALTH PLAN WITH PAYOUTS FOR DENTAL SERVICES, I ASSUME ALL RISKS AND RESPONSIBILITY FOR THE REQUIREMENTS OF ANY COVERED HEALTH PLAN WITH PAYOUTS THAT I AM ELIGIBLE FOR.
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Group Benefits Dental Claim PART 1 DENTIST LAST NAME GIVEN NAME P A T ADDRESS I E N CITY T UNIQUE NO. APT. POSTAL CODE PROV. SPEC. PATIENT'S OFFICE ACCT. NO. D E N T I S PHONE NO. T I HEREBY ASSIGN
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Part 1 - dentist refers to the section of a form or document that specifically relates to dentists.
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To fill out part 1 - dentist, dentists must provide the requested information related to their practice.
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The specific information that must be reported on part 1 - dentist may vary depending on the form or document, but generally it includes details such as the dentist's name, contact information, license number, and practice location.
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