Get Dental Report Form

Filling out the Dental Report Form online is a crucial step in ensuring that dental claims are processed efficiently. This guide will walk you through each section of the form to help you complete it accurately and gather the necessary information.

Follow the steps to complete the Dental Report Form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter the dentist information, including the dentist's name, Social Security Number (SSN) or Tax Identification Number (I.D.), address, license number, and contact information.
3. Provide the patient information by filling in the patient's name, SSN, and coverage information. If the policyholder is not the patient, include their name as well.
4. Details of the patient's insurance should include the insurance carrier's name and telephone number, the patient plan I.D., and the address of the patient's insurance carrier.
5. Include details about the group number and indicate whether the patient has coverage under another dental plan, such as Medicaid. If so, attach additional coverage information if necessary.
6. Document the treatment plan by indicating if the treatment is a result of a crime. Specify the tooth (either by number or letter), and provide a pre-treatment estimate for the services.
7. Describe the service being provided, including the date of service and the fee associated with it.
8. Explain how the service relates to the injury and detail any unusual services necessary, including their relevance.
9. Attach any required fee scale documentation with your submission to ensure clarity on the costs.
10. Once all information is accurately filled out, you can save changes, download, print, or share the completed form as necessary.

Start filling out your Dental Report Form online now to ensure your claims are handled promptly.