Get the free Dental Claim Form - ProHealth Physicians

Dental Claim Form HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services Request for Predetermination / Preauthorization EPS DT/ Title XIX POLICYHOLDER/SUBSCRIBER

How to fill out dental claim form

How to fill out a dental claim form:

1. Start by obtaining a dental claim form from your insurance provider or download it from their website.
2. Fill in your personal information, such as your name, address, and contact details.
3. Provide your insurance information, including the name of your insurance company, policy number, and group number.
4. Indicate the date of service for your dental treatment or procedure that you are claiming.
5. Describe the dental procedure or treatment you received, including the CDT (Current Dental Terminology) codes if available.
6. Include the name and contact information of your dentist or dental provider who performed the treatment.
7. Specify the total cost of the dental services rendered.
8. If applicable, provide any previous payment made by your insurance company or other parties towards the treatment.
9. Attach any supporting documentation, such as dental bills, receipts, or any required radiographs or X-rays.
10. Review the completed form for accuracy and make sure all sections are filled out correctly.
11. Sign and date the form.

Who needs a dental claim form?

1. Individuals who have dental insurance coverage and require reimbursement for dental treatments or procedures may need to fill out a dental claim form.
2. Employers who offer dental insurance as part of their employee benefit package may also need to provide dental claim forms to their employees.
3. Dental service providers or dentists may require patients to complete a dental claim form if they are not able to submit claims directly to the insurance company.

For pdfFiller’s FAQs

What is dental claim form?

Dental claim form is a form used to request reimbursement for dental services provided by a dentist.

Who is required to file dental claim form?

Patients who have received dental services and wish to be reimbursed 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, you will need to provide information such as your personal details, dental service details, and any insurance information.

What is the purpose of dental claim form?

The purpose of dental claim form is to request reimbursement for dental services provided by a dentist.

What information must be reported on dental claim form?

Information such as patient's name, date of service, description of dental services provided, and cost of services must be reported on a dental claim form.

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