Get Dental Claim Form - Anthem

Filling out the Dental Claim Form - Anthem online can be a straightforward process if you follow the correct steps. This guide will walk you through each section of the form to ensure a complete and accurate submission.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to download the form and open it in your preferred editor.
2. Enter the patient's name in the designated field, ensuring the first, middle, and last names are clearly indicated.
3. Indicate the relationship of the patient to the employee by selecting the appropriate option: self, spouse, child, or other.
4. Fill in the patient’s birthdate using the format: month, day, year.
5. Select the patient's sex by marking either male or female.
6. Provide the employee’s name, including first, middle, and last names as requested.
7. Enter the employee's mailing address, ensuring to include all relevant details.
8. Complete the employee's social security number accurately.
9. If applicable, indicate whether the patient is a full-time student and provide the name and city of the school.
10. Fill out the employee’s birthdate using month, day, year format.
11. Provide the name and address of the employer, including city, state, and ZIP code.
12. Indicate if the patient is covered by another dental plan by selecting yes or no.
13. If yes, fill in the details of the other carrier including the employee’s name, employer, and social security number.
14. Ensure both the patient or guardian and the employee/subscriber provide their signatures and dates.
15. For the dentist section, provide the name of the billing dentist or dental entity, including their mailing address.
16. Fill in the dentist's social security number or tax identification number.
17. Provide the dentist's license number as requested.
18. Indicate the date of the first visit for the current dental series.
19. Specify the phone number of the dentist or dental entity.
20. Select the place of treatment by marking the appropriate option: office, hospital, urgent care facility, or other.
21. Answer questions regarding the nature of the treatment, including if it was due to an accident or occupational injury.
22. List all specific procedures, dates of service, and associated fees, ensuring all teeth involved are identified.
23. Review the entire form for accuracy and ensure all required sections are filled.
24. Save the completed form, and then download, print, or share it as needed.

Take the next step towards submitting your dental claim by completing the form online today.