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Delta Dental of New York, Inc. ATTENDING DENTIST S STATEMENT P.O. Box 2105 Mechanicsburg, PA 17055-6999 (717) 766-8500 (800) 932-0783 TTY/TDD 888-373-3582 www.deltadentalins.com SIGN BELOW FOR PREDETERMINATION

How to fill out attending dentist s statement

Who needs attending dentist's statement?

1. Insurance companies: Insurance companies often require an attending dentist's statement to verify the dental treatment received by the patient. This statement provides details about the procedures performed, the extent of coverage, and any necessary follow-up care.
2. Legal entities: Persons involved in legal proceedings, such as personal injury or medical malpractice cases, may need an attending dentist's statement to provide evidence of the dental injuries sustained and the treatment received.
3. Employers: Some employers may require an attending dentist's statement if an employee needs time off for dental treatment or if there are reimbursement policies in place for dental procedures.

How to fill out attending dentist's statement?

1. Personal Information: Begin by providing the patient's personal information, including their full name, date of birth, address, contact number, and insurance policy details.
2. Dentist's Information: Include the attending dentist's name, practice address, contact information, and any relevant identification numbers, such as license or registration numbers.
3. Patient's Dental History: Document the patient's dental history, including any past treatments, procedures, or oral health issues. This information helps provide context for the current dental condition.
4. Dental Diagnosis: Clearly state the diagnosis for which the patient is seeking treatment. This could include specific dental conditions, injuries, or diseases identified by the attending dentist.
5. Treatment Plan: Outline the recommended and performed treatments for the patient. Include details such as the date of each procedure, the nature of the treatment, and any anticipated future services or follow-up care.
6. Medications: List any prescribed medications related to the dental treatment. Include the dosage, frequency, and duration of each medication if applicable.
7. Cost Estimates: Provide an estimated cost breakdown for the dental treatment, including any out-of-pocket expenses or insurance coverage. This information helps insurance companies or employers assess the financial implications of the treatment.
8. Dentist's Signature and Date: Sign and date the attending dentist's statement to authenticate the information provided. This signature indicates that the dentist is accountable for the accuracy and completeness of the statement.

Remember, the specific format of the attending dentist's statement may vary depending on the requirements of the requesting party. Always review the instructions provided by the requesting entity and tailor the statement accordingly.

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What is attending dentist s statement?

Attending dentist's statement is a form filled out by the treating dentist that provides details about the dental treatment provided to the patient.

Who is required to file attending dentist s statement?

The treating dentist who performed the dental treatment is required to file the attending dentist's statement.

How to fill out attending dentist s statement?

The attending dentist's statement should be filled out with details about the dental treatment provided, including dates of service, procedures performed, and patient information.

What is the purpose of attending dentist s statement?

The purpose of the attending dentist's statement is to document the dental treatment provided to the patient for insurance and record-keeping purposes.

What information must be reported on attending dentist s statement?

The attending dentist's statement must include details such as the dates of service, procedures performed, tooth numbers, patient information, and the treating dentist's signature.