Get Delta Dental Of Arkansas Claims Address

FOR D. D. USE ONLY ATTENDING DELTA DENTAL OF ARKANSAS P. O. Box 15965 North Little Rock Arkansas 72231 800 462-5410 Fax Claims to 888-900-1373 501 835-3400 DENTIST S STATEMENT CHECK ONE FOR PREDETERMINATION FOR PAYMENT 1. PROCEDURE NUMBER FEE HOW 31. IS TREATMENT FOR ORTHODONTICS MANY IF NO REASON FOR REPLACEMENT IF SERVICES ALREADY COMMENCED ENTER 30. DATE OF PRIOR DATE APPLIANCE PLACED MOS. TREATMENT REMAINING G 32. REMARKS FOR UNUSUAL SERVICES WARNING ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE DEFRAUD OR DECEIVE ANY INSURER MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. IDENTIFY MISSING TEETH WITH X FACIAL I HEREBY CERTIFY THAT THE PROCEDURES AS INDICATED BY DATE ABOVE HAVE BEEN PERFORMED ACCORDING TO THE PROVISIONS OF THE DENTAL CARE PLAN NAMED ABOVE. ALSO THAT THE FEES SUBMITTED ARE THE ACTUAL FEES I HAVE CHARGED AND INTEND TO COLLECT FOR THESE PROCEDURES. I AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE OF THIS FORM AND PAYMENT FOR SAID PROCEDURES IS NOW DUE. DENTIST SIGNATURE X TOTAL DATE NATIONAL PROVIDER ID I HEREBY ACCEPT THE FOREGOING TREATMENT PLAN AND AUTHORIZE RELEASE OF ANY INFORMATION RELATING TO THIS CLAIM. I UNDERSTAND THAT THE PORTION OF THE DENTIST S CHARGES COVERED UNDER THE DENTAL CARE PLAN NAMED ABOVE WILL BE PAID DIRECT TO THE DENTIST UNLESS THE DENTIST IS NOT PARTICIPATING WITH A DELTA PLAN AND I AM PERSONALLY RESPONSIBLE FOR ANY PORTION OF THOSE CHARGES NOT COVERED BY THE PLAN. PATIENT PARENT OR MEMBER SIGNATURE X MAIL ORIGINAL TO PLAN OR FAX TO 888-900-1373 RETAIN COPY FOR YOUR FILE.. PATIENT NAME 2. RELATIONSHIP TO MEMBER SELF P A T I E N SPOUSE DGHTR SON 4. PATIENT BIRTHDATE OTHER M 6. EMPLOYEE/SUBSCRIBER NAME FIRST MIDDLE MO DAY YEAR 5. IF FULL TIME STUDENT SCHOOL CITY F 9. NAME OF GROUP DENTAL PROGRAM LAST TELEPHONE NUMBER 10. EMPLOYER COMPANY NAME AND ADDRESS CITY STATE ZIP S C O D 11. GROUP NUMBER 12. LOCATION LOCAL 13. ARE OTHER FAMILY MEMBERS EMPLOYED EMPLOYEE NAME I. D. NO. BIRTHDATE 14. NAME AND ADDRESS OF EMPLOYER IN ITEM 13. 15. IS PATIENT COVERED BY ANOTHER DENTAL PLAN DENTAL PLAN NAME UNION LOCAL GROUP NO. NAME AND ADDRESS OF CARRIER 16. DENTIST NAME 25. IS TREATMENT RESULT OF OCCUPATIONAL ILLNESS OR INJURY 17. MAILING ADDRESS 27. OTHER ACCIDENT YES IF YES ENTER BRIEF DESCRIPTION AND DATES 28. ARE ANY SERVICES COVERED BY ANOTHER PLAN 18. Tax Identification No* 22. FIRST VISIT DATE CURRENT SERIES NO 19. Dentist License No* 20. National Provider ID 23. PLACE OF TREATMENT OFFICE DESCRIPTION HOSP. ECF 21. Dentist Phone No* 24. RADIOGRAPHS OR MODELS ENCLOSED 29. IF PROSTHESIS OR SINGLE CROWN S IS THIS INITIAL PLACEMENT YES ATTACH X-RAYS SECURELY DATE SERVICE TOOTH PERFORMED OR SURFACE LETTER MO. PROCEDURE NUMBER FEE HOW 31. IS TREATMENT FOR ORTHODONTICS MANY IF NO REASON FOR REPLACEMENT IF SERVICES ALREADY COMMENCED ENTER 30. DATE OF PRIOR DATE APPLIANCE PLACED MOS* TREATMENT REMAINING G 32. REMARKS FOR UNUSUAL SERVICES WARNING ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE DEFRAUD OR DECEIVE ANY INSURER MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON* IDENTIFY MISSING TEETH WITH X FACIAL I HEREBY CERTIFY THAT THE PROCEDURES AS INDICATED BY DATE ABOVE HAVE BEEN PERFORMED ACCORDING TO THE PROVISIONS OF THE DENTAL CARE PLAN NAMED ABOVE* ALSO THAT THE FEES SUBMITTED ARE THE ACTUAL FEES I HAVE CHARGED AND INTEND TO COLLECT FOR THESE PROCEDURES* I AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE OF THIS FORM AND PAYMENT FOR SAID PROCEDURES IS NOW DUE* DENTIST SIGNATURE X TOTAL DATE NATIONAL PROVIDER ID I HEREBY ACCEPT THE FOREGOING TREATMENT PLAN AND AUTHORIZE RELEASE OF ANY INFORMATION RELATING TO THIS CLAIM.