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United Concordia
Dental Claims Administrator
PO Box 69441
Harrisburg, PA 171069441
CHECK ONE:
q DENTISTS PRETREATMENT ESTIMATE
q DENTISTS STATEMENT OF ACTUAL SERVICESATTENDING DENTISTS STATEMENTCARRIERNAME
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How to fill out attending dentists statement
How to fill out attending dentists statement
01
To fill out the attending dentists statement:
02
Begin by providing your personal information, such as your name, contact information, and the date.
03
Indicate the patient's information, including their name, age, and any relevant medical history.
04
Describe the dental treatment or procedure that was provided to the patient.
05
Mention any complications or side effects that occurred during or after the treatment.
06
Include the date(s) the treatment was administered and the duration of the treatment.
07
Sign and date the statement to certify its authenticity.
08
Provide any additional documentation or attachments, if necessary.
09
Make a copy of the completed statement for your records and submit the original to the relevant party.
Who needs attending dentists statement?
01
Attending dentists statements are generally needed by insurance companies, legal authorities, or third-party payers to verify and document the dental treatment provided to a patient. This statement helps in establishing the authenticity and details of the treatment for reimbursement purposes or legal proceedings.
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What is attending dentists statement?
Attending dentist statement is a document in which the treating dentist provides details about the dental treatment provided to a patient.
Who is required to file attending dentists statement?
The attending dentist who provided treatment to a patient is required to file the attending dentist statement.
How to fill out attending dentists statement?
The attending dentist must fill out the statement with details of the treatment provided, including procedures performed, dates of treatment, and any additional relevant information.
What is the purpose of attending dentists statement?
The purpose of the attending dentist statement is to document the dental treatment provided to a patient for insurance and record-keeping purposes.
What information must be reported on attending dentists statement?
The attending dentist must report details of the treatment provided, including procedures performed, dates of treatment, and any relevant notes about the patient's oral health.
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