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Complete and send to: Maritain Health P.O. Box 853921 Richardson, TX 750853921 Fax: 1.763.852.5057Health Claim FormIMPORTANT: Please have your doctor or supplier of medical services complete the reverse
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To fill out the dental claim form txwest region0319indd, follow these steps:
02
Start by entering the patient's information, including their name, date of birth, address, and contact information.
03
Next, provide details about the dental provider, such as their name, address, phone number, and tax ID.
04
Indicate the primary insurance information, including the policyholder's name, policy number, and group number.
05
Specify the dental procedure details, including the date of service, description of the treatment, tooth number(s) involved, and fee charged.
06
If there is secondary insurance, provide the policyholder's name, policy number, and group number for that as well.
07
Attach any necessary supporting documents, such as X-rays or treatment plans.
08
Review the completed form to ensure all information is accurate and legible.
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Sign and date the form.
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Submit the dental claim form to the appropriate insurance provider.

Who needs dental claimtxwest region0319indd?

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Anyone who has received dental treatment and wishes to claim reimbursement from their insurance provider needs the dental claim form txwest region0319indd.
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Dental claimtxwest region0319indd refers to a specific dental claim form used in the West region, designated for filing claims for dental services provided.
Dental professionals, such as dentists and dental hygienists, who provide services and seek reimbursement for those services must file dental claimtxwest region0319indd.
To fill out dental claimtxwest region0319indd, you need to enter patient details, service descriptions, procedure codes, and total charges in the designated fields of the form.
The purpose of dental claimtxwest region0319indd is to facilitate the billing process for dental services and ensure that dental providers are compensated for the care they provide to patients.
Information that must be reported includes patient identification, provider details, specific dental procedures performed, dates of service, and the associated costs.
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