Get the free DENTAL - Claim Form (Cigna) - BorgWarner

Group Dental Claim Form Insured and/or Administered by Connecticut General Life Insurance Company CHINA Dental Borg Warner Inc. MAIL THIS FORM TO: CHINA Healthcare Service Center P.O. Box 188036 Chattanooga,

How to fill out dental - claim form

How to fill out a dental claim form:

1. Begin by carefully reading the instructions provided on the form. Make sure you understand each section and the information required.
2. Fill in your personal information accurately, including your full name, date of birth, address, and contact information.
3. Provide your insurance information, including the name of your insurance company, policy number, and group number. If you have secondary insurance, include that information as well.
4. Indicate the name and contact information of the dental service provider who treated you. This may include their name, address, and phone number.
5. Include the date of the dental service, as well as a detailed description of the treatment received. Specify the tooth or teeth involved, the procedures performed, and any additional information required by the form.
6. Fill out the fee section, indicating the charges for each service provided. Ensure accuracy, as any inconsistencies may result in a delay or denial of your claim.
7. If necessary, attach any supporting documentation such as receipts, x-rays, or referral forms. These documents can help validate your claim and expedite the processing time.
8. Review the form for any errors or missing information. Double-check your entries to ensure accuracy and completeness.
9. Sign and date the form as required, certifying that the information provided is true and accurate to the best of your knowledge.

Who needs a dental claim form?

A dental claim form is typically required by individuals who have dental insurance and have received dental services. This form allows them to submit a claim to their insurance provider to seek reimbursement for the services rendered. In some cases, the dental service provider may also need to fill out a portion of the form, providing their information and details of the treatment provided.

For pdfFiller’s FAQs

What is dental - claim form?

The dental claim form is a document used to request reimbursement for dental services from an insurance provider.

Who is required to file dental - claim form?

Dental patients who have received dental services covered by their insurance provider are required to file a dental claim form.

How to fill out dental - claim form?

To fill out a dental claim form, the patient needs to provide personal information, details of dental services received, cost of services, and any other relevant information requested by the insurance provider.

What is the purpose of dental - claim form?

The purpose of the dental claim form is to request reimbursement for dental services covered by an insurance provider.

What information must be reported on dental - claim form?

The dental claim form must include personal information, details of dental services received, cost of services, and any other information requested by the insurance provider.

When is the deadline to file dental - claim form in 2023?

The deadline to file the dental claim form in 2023 is typically determined by the insurance provider and may vary.

What is the penalty for the late filing of dental - claim form?

The penalty for late filing of the dental claim form may include a delayed reimbursement or denial of the claim by the insurance provider.

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