Dental Claim Form
1. Type of Transaction (Check all applicable boxes) Statement of Actual Services EPSDT/Title XIX 2. Predetermination/Preauthorization Number Request for Predetermination/Preauthorization
(603) 223-1234 (800) 832-5700 Delta Dental Plan of Maine Delta Dental Plan of New Hampshire Delta Dental Plan of Vermont PRIMARY INSURED INFORMATION
12. Name (Last, First, Middle Initial,...
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