Get the free Monthly Orthodontia Claim Form

FAX: 585-389-7003 Patches Employee Services: 877-244-1771, automated system available 24/7, representatives available Monday Friday 8:00 a.m. 8:00 p.m. ET Submit or view claims ONLINE: https://benefits.paychex.com

How to fill out monthly orthodontia claim form

How to fill out a monthly orthodontia claim form:

Start by entering your personal information:

1. Write your full name and contact details, including your address and phone number.
2. Provide your date of birth and any identification numbers required, such as your insurance policy number.

Fill in the orthodontist's information:

1. Include the name and address of your orthodontist or dental office providing the treatment.
2. Provide the orthodontist's phone number and any other necessary contact details.

Indicate the treatment details:

1. Specify the start and end dates of the orthodontic treatment.
2. Describe the type of treatment received, such as braces or Invisalign.
3. Include any additional services or procedures performed, if applicable.

Provide information about your insurance coverage:

1. Enter your insurance provider's name and contact details.
2. Include your insurance identification number and group number, if applicable.
3. Indicate the policyholder's name if you are not the policyholder yourself.

Include any other relevant details:

1. If there were any changes in your insurance coverage or policy, mention them.
2. If you have made any prior claims for orthodontic treatment, note the dates and details.

Attach supporting documents, if required:

1. Check if the claim form requires any supporting documents, such as invoices, receipts, or treatment plans.
2. Make sure all documents are legible and clearly labeled with your name and policy information.

Who needs a monthly orthodontia claim form?

A monthly orthodontia claim form is needed by individuals who have dental insurance coverage and are undergoing orthodontic treatment. Such individuals can use this form to request reimbursement from their insurance provider for the expenses incurred during the course of their orthodontic treatment. It is typically required by insurance companies to process and evaluate the claim accurately.

For pdfFiller’s FAQs

What is monthly orthodontia claim form?

Monthly orthodontia claim form is a form used to report expenses related to orthodontic treatment on a monthly basis.

Who is required to file monthly orthodontia claim form?

The individual undergoing orthodontic treatment or their legal guardian is required to file the monthly orthodontia claim form.

How to fill out monthly orthodontia claim form?

The monthly orthodontia claim form can be filled out by entering all relevant information about the orthodontic treatment expenses incurred during the month.

What is the purpose of monthly orthodontia claim form?

The purpose of the monthly orthodontia claim form is to track and report expenses related to orthodontic treatment for insurance or reimbursement purposes.

What information must be reported on monthly orthodontia claim form?

The monthly orthodontia claim form must include details such as the date of treatment, type of treatment, amount charged, and any payments made.

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