GEHA Dental Claim Form 2006 free printable template

Dental Claim Forehead INFORMATIONGEHA Connection Dental Federal1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services. O. Box 21542 Reagan, MN 55121Request for Predetermination

How to fill out GEHA Dental Claim Form

How to fill out GEHA Dental Claim Form

1. Obtain the GEHA Dental Claim Form from the official website or your dentist's office.
2. Fill out your personal information including your name, address, phone number, and member ID.
3. Specify the patient information if different from the member.
4. List the dental services provided, including dates, procedure codes, and descriptions.
5. Attach any necessary supporting documents such as receipts or treatment plans.
6. Sign and date the form to verify that the information provided is accurate.
7. Submit the completed form via mail or online as directed on the form.

Who needs GEHA Dental Claim Form?

1. Members of GEHA who have received dental services and wish to claim reimbursement.
2. Dependents covered under a GEHA dental plan who have received eligible dental treatments.
3. Health care providers who need to bill GEHA for services provided to a member.

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What is GEHA Dental Claim Form?

The GEHA Dental Claim Form is a document used to submit claims for dental services covered under the Government Employees Health Association (GEHA) dental insurance plan.

Who is required to file GEHA Dental Claim Form?

Members of the GEHA dental insurance plan who receive dental services that are eligible for reimbursement are required to file the GEHA Dental Claim Form.

How to fill out GEHA Dental Claim Form?

To fill out the GEHA Dental Claim Form, individuals need to provide their personal information, details of the services received, the dentist's information, and any relevant insurance information as required by the form.

What is the purpose of GEHA Dental Claim Form?

The purpose of the GEHA Dental Claim Form is to facilitate the reimbursement process for members who have incurred expenses for dental services under their GEHA dental plan.

What information must be reported on GEHA Dental Claim Form?

The GEHA Dental Claim Form must include the claimant's name, address, policy number, details of dental services rendered, the dates of service, name and address of the dentist, and any other supporting information as specified on the form.