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DENTAL SERVICE AUTHORIZATION (SA) REQUEST Complete the following form and fax to Conduct at 866.780.2219. To request an update to an approved SA, complete a Dental SA Update Request. For Dental Professional
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How to fill out dental service authorization sa
How to fill out dental service authorization sa
01
Obtain the dental service authorization form from your dentist or dental provider.
02
Fill out your personal information such as name, address, and phone number.
03
Provide details of the dental services being requested, including the type of service needed and the reason for the service.
04
Include any relevant insurance information, such as policy number and group ID.
05
Sign and date the form before submitting it to your insurance company for review.
Who needs dental service authorization sa?
01
Anyone who is seeking dental services that are covered by their insurance policy may need to fill out a dental service authorization form.
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What is dental service authorization sa?
Dental service authorization sa is a form used to request approval for dental services before they are provided.
Who is required to file dental service authorization sa?
Dentists and dental providers are required to file dental service authorization sa.
How to fill out dental service authorization sa?
Dental service authorization sa should be filled out with the patient's information, the services requested, and any necessary supporting documentation.
What is the purpose of dental service authorization sa?
The purpose of dental service authorization sa is to ensure that the requested dental services are medically necessary and will be covered by insurance.
What information must be reported on dental service authorization sa?
The dental service authorization sa must include the patient's name, date of birth, insurance information, treatment plan, and provider information.
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