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ATTENDING DENTIST S STATEMENT Dental Products CHECK ONE: USE ONE FORM PER SERVICE LINE MAIL TO: PRE-TREATMENT ESTIMATE 1. PATIENT NAME FIRST PATIENT INFORMATION BLUE CROSS AND BLUE SHIELD OF NEW MEXICO
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How to fill out attending dentist39s statement
Who needs attending dentist's statement?
01
Patients who have received dental treatment and require a statement from the attending dentist for insurance or reimbursement purposes.
02
Dentists who need to provide detailed information regarding the treatment provided to their patients.
03
Insurance companies or reimbursement agencies who require a comprehensive statement to process claims accurately.
How to fill out attending dentist's statement?
01
Start by entering the patient's personal information, including their name, address, contact details, and insurance information if applicable.
02
Clearly state the date of the dental treatment provided.
03
Specify the type of treatment rendered, such as routine check-up, extraction, filling, or any other dental procedure.
04
Provide a detailed description of the treatment, including the specific tooth or area treated, any additional procedures performed, and any dental materials used.
05
Include the fees charged for each treatment, broken down by procedure, and indicate if any payment has already been received.
06
Provide an itemized list of any dental X-rays or diagnostic tests conducted, along with their corresponding charges if applicable.
07
If the patient has any dental conditions or special considerations, include this information in the statement for a thorough overview.
08
Sign and date the attending dentist's statement to authenticate its accuracy.
09
If required, attach any supporting documentation such as dental records, X-ray reports, or treatment plans.
10
Make copies of the completed statement for both the patient and the dentist's records for future reference.
Remember to always check the specific requirements of the insurance company or reimbursement agency regarding the format and information required in the attending dentist's statement.
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What is attending dentist's statement?
Attending dentist's statement is a document filled out by the dentist providing treatment to the patient, stating the details of the treatment provided.
Who is required to file attending dentist's statement?
The attending dentist is required to file the attending dentist's statement.
How to fill out attending dentist's statement?
Attending dentist's statement can be filled out with the details of the treatment provided to the patient, including procedures, dates, and charges.
What is the purpose of attending dentist's statement?
The purpose of attending dentist's statement is to provide a record of the treatment provided to the patient and to support insurance claims.
What information must be reported on attending dentist's statement?
The attending dentist's statement must report the details of the treatment provided, including procedures, dates, charges, and patient information.
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