Get Attending Dentist S Statement - Macalester College - Macalester

Filling out the ATTENDING DENTIST S STATEMENT is a crucial step for students seeking dental benefits. This guide provides detailed, step-by-step instructions to help you accurately complete the form online, ensuring a smooth submission process.

Follow the steps to complete the ATTENDING DENTIST S STATEMENT online.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. Begin by checking the appropriate box to indicate whether you are submitting a dentist’s pre-treatment estimate or a statement of actual services.
3. Fill in the patient’s name, including the first name, middle initial, and last name.
4. Indicate the patient’s sex by selecting either male or female.
5. Specify the patient’s relationship to the employee from the options provided: self, child, spouse, or other.
6. Enter the patient’s birthdate in the specified format (MM/DD/YYYY).
7. If the patient is a full-time student, provide the name of the school and the city where it is located.
8. Input the employee/subscriber’s name along with their mailing address.
9. Enter the employee/subscriber’s social security or identification number.
10. Provide the employee/subscriber’s birthdate in the specified format.
11. Indicate the employer's name and address.
12. Enter the group number associated with the insurance plan.
13. If the patient is covered by another dental plan, answer yes and provide the name and address of that carrier.
14. Complete any sections concerning additional employers and group numbers as required.
15. If applicable, indicate whether the patient is covered by a medical plan and provide relevant details.
16. Authorize the release of any information relating to this claim by providing the patient’s or parent’s signature.
17. Fill in the billing dentist’s name and address.
18. Complete the details regarding the treatment, including the type of services rendered and the related fees.
19. List teeth being treated, showing any that are missing, along with a description of each service provided.
20. Ensure that all required signatures are completed to certify that the services indicated have been performed.
21. Finally, review all entries for accuracy, then proceed to save changes, download, print, or share the completed form as needed.

Start filling out your ATTENDING DENTIST S STATEMENT online today for hassle-free dental benefit processing.