CA Delta Dental 3460 2009 free printable template
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ENROLLMENT/CHANGE FORM CA
DUAL CHOICER GROUP USE ONLY
Group No. Delta Dental of California
www.deltadentalins.comDelta Dental Preselect a Plan:ORDeltaCareP. O. Box 429086
San Francisco, CA 941429086VERY
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How to fill out CA Delta Dental 3460
01
Obtain the CA Delta Dental 3460 form from the Delta Dental website or your dental office.
02
Fill out the 'Patient Information' section with the patient's name, birth date, and contact details.
03
Provide the 'Subscriber Information' including the policyholder's name, subscriber ID number, and relationship to the patient.
04
Complete the 'Procedure Information' section by listing the dental procedures performed, including codes and descriptions.
05
Include the date of service for each procedure.
06
Fill in the 'Dentist Information' by providing the dentist's name, license number, and office address.
07
Sign and date the form in the designated area to confirm the accuracy of the information provided.
08
Submit the completed form to Delta Dental through the preferred method indicated on the form (mail, fax, or online submission).
Who needs CA Delta Dental 3460?
01
Patients receiving dental services who need to claim benefits from their Delta Dental insurance.
02
Dentists who are submitting claims for services rendered to their patients covered by Delta Dental.
03
Policyholders who want to ensure proper documentation for dental procedures covered under their plan.
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What is CA Delta Dental 3460?
CA Delta Dental 3460 is a form used by dental service providers in California to report specific dental procedures and services for reimbursement and management purposes.
Who is required to file CA Delta Dental 3460?
Dental providers who participate in the Delta Dental program and wish to receive reimbursements for services rendered to patients covered by Delta Dental insurance plans must file CA Delta Dental 3460.
How to fill out CA Delta Dental 3460?
To fill out CA Delta Dental 3460, providers must include the patient's information, the details of the dental services provided, the corresponding procedure codes, and any relevant billing information as required by the form.
What is the purpose of CA Delta Dental 3460?
The purpose of CA Delta Dental 3460 is to facilitate the processing of dental claims, ensuring that providers are reimbursed for the services they deliver to patients covered by Delta Dental insurance.
What information must be reported on CA Delta Dental 3460?
The information that must be reported on CA Delta Dental 3460 includes patient demographics, provider information, service dates, procedure codes, and any other relevant details that pertain to the dental services rendered.
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