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CLAIM FORM FOR DDS USE ONLY ATTENDING DENTISTS STATEMENT CHECK ONE: Delta Dental of Kansas P.O. Box 789769 Wichita, KS 672789769 1. PATIENT NAME FIRST MIDDLE LAST FOR PREDETERMINATION FOR PAYMENT
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How to fill out delta-dental-claim-form-feb-13pdf
How to fill out delta-dental-claim-form-feb-13pdf:
01
Start by downloading the delta-dental-claim-form-feb-13pdf from the official Delta Dental website or obtain a physical copy from your dentist's office.
02
Review the instructions on the form carefully to familiarize yourself with the required information and any specific guidelines.
03
Begin filling out the form by providing your personal information, such as your name, address, and contact details. It is important to ensure the accuracy of this information.
04
Next, fill in your dental insurance details. This may include your policy or group number, identification number, and the name of the primary dental insurance holder if applicable.
05
In the section for dentist or dental office information, provide the name, address, and contact details of your dental care provider.
06
Indicate the date of service for which you are submitting a claim. This should align with the dates of your dental treatment or procedure.
07
Carefully document the dental procedures for which you are filing a claim. Include the description of the service, procedure codes, and the tooth numbers if applicable.
08
For each procedure, include the dentist's diagnosis or reason for treatment, as well as the fee charged by the dental provider.
09
If you have other dental insurance coverage, indicate the details in the appropriate section of the claim form and attach any necessary supporting documents.
10
Double-check all the information you have entered to ensure its accuracy and completeness. Make sure you have signed and dated the form where required.
11
Retain a copy of the completed claim form for your records before submitting it to the appropriate address provided by your dental insurance company.
Who needs delta-dental-claim-form-feb-13pdf:
01
Individuals who have dental insurance coverage through Delta Dental or a Delta Dental affiliate may need the delta-dental-claim-form-feb-13pdf to submit claims for reimbursement of dental expenses.
02
Those who have received dental treatment or procedures from a dentist that falls under the Delta Dental network may require this claim form to request reimbursement from their dental insurance provider.
03
Patients seeking to obtain refunds for eligible dental services not covered directly by their dental office or dentist's office may need to utilize this claim form to submit the necessary information and documentation to their dental insurance company.
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What is delta-dental-claim-form-feb-13pdf?
It is a form used for submitting dental insurance claims to Delta Dental.
Who is required to file delta-dental-claim-form-feb-13pdf?
Patients who have received dental services covered by Delta Dental insurance.
How to fill out delta-dental-claim-form-feb-13pdf?
You need to provide your personal information, details of the dental services received, and any supporting documentation, such as receipts or treatment plans.
What is the purpose of delta-dental-claim-form-feb-13pdf?
The purpose is to request reimbursement for dental services covered by Delta Dental insurance.
What information must be reported on delta-dental-claim-form-feb-13pdf?
Personal details, dental procedure codes, date of service, provider information, and any supporting documents.
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