Get Delta Dental Mn

Filling out the Delta Dental of Minnesota online form is a straightforward process that requires you to provide essential information about the patient, employee, and dental services. This guide will walk you through each section, ensuring you complete the form accurately and efficiently.

Follow the steps to complete the Delta Dental Mn form effectively.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering the patient's name in the designated fields. Ensure that you provide the first name, middle initial, and last name for complete identification.
3. Indicate the patient's relationship to the employee by selecting from options such as self, child, spouse, or other.
4. Select the patient's sex by marking 'M' for male or 'F' for female.
5. Provide the patient's birthdate by entering the month, day, and year in the designated fields.
6. If the patient is a full-time student, include the name of the school and city.
7. Fill in the employee or subscriber’s name and their mailing address to ensure all communications reach the correct person.
8. Input the employee or subscriber’s social security or identification number in the specified field.
9. Enter the employee or subscriber’s birthdate by filling in the month, day, and year.
10. State the employer's name and address where the employee works to clarify the employment status.
11. Fill in the group number associated with the employee's insurance.
12. Complete the question regarding any other dental plans the patient may have by selecting 'Yes' or 'No.' If 'Yes,' provide the name and address of the other carrier.
13. Indicate whether the patient is covered by a medical plan by answering 'Yes' or 'No.' If 'Yes,' fill out the employee or subscriber name, along with their social security or identification number.
14. Carefully review the treatment plan and authorize the release of any necessary information. The patient or authorized individual should sign the form.
15. Include the name of the billing dentist or dental entity and the date to confirm billing details.
16. For treatment details, provide information sequentially for each tooth listed, including the description of service, date performed, and associated procedure numbers.
17. Finally, make sure to sign as the treating dentist, write their license number, and enter the total fee charged for services rendered.
18. Once all sections are completed, you can save your changes, download the form for your records, print it out, or share it as needed.

Complete your Delta Dental Mn form online today to ensure timely processing of your dental claims.