Get the free Delta Dental: Claim Form - benefits.leidos.com
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Delta Dental of Virginia 4818 Starkey Road Roanoke, VA 24018 5409898000 or 8002376060 (Phone) 5404919717 (Fax) Claim For Payment Claim For PredeterminationEMPLOYEE/SUBSCRIBER INFORMATION 1. Name (First,
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How to fill out delta dental claim form
How to fill out delta dental claim form
01
To fill out a Delta Dental claim form, follow the steps below:
02
Obtain the Delta Dental claim form, either by downloading it from the Delta Dental website or requesting it from your dentist.
03
Fill out the patient information section, including your name, address, phone number, and date of birth.
04
Provide your insurance information, including your Delta Dental member ID and group number.
05
Indicate the treatment date and the name of the dental provider who performed the service.
06
Describe each dental procedure performed, including the tooth number and type of service provided.
07
Include any supporting documentation, such as x-rays or receipts, if required.
08
Sign and date the form.
09
Make a copy of the completed form for your records.
10
Submit the form to Delta Dental for processing, either by mail or through their online portal.
11
Keep track of the claim's progress and follow up if necessary.
Who needs delta dental claim form?
01
Anyone who has received dental treatment covered by Delta Dental and wants to claim insurance benefits can fill out the Delta Dental claim form.
02
This includes Delta Dental members who have undergone dental procedures and are seeking reimbursement.
03
Orthodontic patients who have dental coverage through Delta Dental and have incurred expenses related to braces or other orthodontic treatments may also need to fill out the claim form.
04
Additionally, dependents covered under a Delta Dental plan may need to fill out the claim form if they have received dental treatment.
05
It is recommended to consult with your dentist or insurance provider to determine if you should fill out the Delta Dental claim form.
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What is delta dental claim form?
The delta dental claim form is a document used to submit claims for dental services to Delta Dental for payment.
Who is required to file delta dental claim form?
Any patient who has received dental services covered by Delta Dental insurance is required to file a delta dental claim form.
How to fill out delta dental claim form?
To fill out a delta dental claim form, you need to provide information such as patient's personal details, details of the dental services provided, and any other relevant information requested on the form.
What is the purpose of delta dental claim form?
The purpose of the delta dental claim form is to request reimbursement for dental services provided to a patient covered by Delta Dental insurance.
What information must be reported on delta dental claim form?
Information such as patient's name, date of birth, dental provider's information, description of services provided, treatment dates, and any other information requested by Delta Dental.
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