Get 1223p0300x

Filling out the 1223p0300x form online can be a straightforward process with the right guidance. This document serves as a comprehensive guide to assist users in completing each section of the form accurately and effectively.

Follow the steps to fill out the 1223p0300x form with ease.

1. Click the ‘Get Form’ button to access the form and open it in your editor.
2. Begin by entering the Primary Payer's name and address in Item 3. Ensure that this information fits appropriately in a standard #10 window envelope, and fold the form along the 'tickmarks' provided in the margins.
3. In the upper-right corner, input the third-party payer's claim or control number if applicable.
4. Fill out all required fields with complete information, including names and addresses in Items 3, 11, 12, 20, and 48. Remember to include the full zip codes.
5. When entering dates in Items 6, 13, 21, 24, 36, 37, 41, 44, and 53, be sure to use the four-digit year format.
6. If reporting multiple procedures that exceed the number of lines available on the form, complete an additional claim form for the remaining procedures.
7. Proceed to Item 8 to enter the subscriber's Social Security Number (SSN) or other assigned identifier. Repeat this step for Item 15, which also requires the subscriber's SSN or identifier.
8. In Item 16, provide the subscriber's or employer group's Plan or Policy Number, also known as the Certificate Number.
9. If the patient is not the Primary Subscriber, complete Items 19-23. For Item 19, mark 'FTS' for full-time students or 'PTS' for part-time students, if applicable.
10. Enter applicable dental procedure codes from the current version of the Code on Dental Procedures and Nomenclature in Item 29.
11. In Item 31, specify the dentist’s full fee for the dental procedure reported.
12. Save changes, download, print, or share the completed form as necessary.

Complete your 1223p0300x form online today for a seamless filing experience.