Get the free Davis Dental Claim Form - My Benefits Navigator

Plan Name: (CHECK ONE) Return this form to the claims' processor: DAVIS HEALTH SYSTEM, INC. HEALTH CARE PLAN DENTAL CLAIM FORM Benefit Assistance Corporation PO Box 950, Hurricane, WV 25526 Plan Administrator

How to fill out davis dental claim form

How to fill out a Davis Dental claim form:

1. Start by carefully reading the instructions provided on the form. Understand the required information and any supporting documents that may be needed.
2. Begin by filling out your personal information, including your name, address, date of birth, and contact details. Ensure that all information is accurate and up to date.
3. Provide your insurance information, including the name of the insurance provider, policy number, and any other required details.
4. Next, indicate the patient's information if it is different from your own. Include their name, date of birth, and relationship to the policyholder.
5. Specify the dental services received by providing details such as the date of each service, the service or procedure performed, and the associated fees.
6. Include any supporting documents, such as invoices, receipts, or explanation of benefits (EOB) forms, which may be required for claim processing.
7. Double-check all the information provided to ensure accuracy and completeness.
8. Sign and date the form, indicating your consent and authorization for the claims submission.
9. Keep a copy of the completed form and any supporting documents for your records.

Who needs a Davis Dental claim form:

1. Policyholders: Individuals who have dental insurance coverage with Davis Dental and have received dental services that are eligible for reimbursement.
2. Dependents: Family members or individuals covered under the policyholder's dental insurance plan who have received dental services that are eligible for reimbursement.
3. Dental service providers: Dentists or dental clinics that have provided services to individuals covered by Davis Dental insurance and need to submit claims for reimbursement.

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What is davis dental claim form?

The davis dental claim form is a form used to submit dental insurance claims for reimbursement of dental services.

Who is required to file davis dental claim form?

Patients who have received dental services and would like to be reimbursed by their insurance are required to file davis dental claim form.

How to fill out davis dental claim form?

To fill out the davis dental claim form, patients must provide their personal information, details of the dental services received, and any relevant insurance information.

What is the purpose of davis dental claim form?

The purpose of the davis dental claim form is to request reimbursement from dental insurance companies for dental services provided.

What information must be reported on davis dental claim form?

Information such as patient's personal details, dentist information, treatment performed, fees charged, and insurance information must be reported on davis dental claim form.