Follow the steps to successfully complete the Denti-cal claim form.

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. Enter the patient's name in the format of Last name, First name, and Middle initial in the designated field.
3. Input the patient's Social Security number as required in the corresponding box.
4. Select the patient's sex from the available options provided.
5. Fill in the patient's birthdate to establish their age at the time of service.
6. Provide the patient's Medi-Cal ID number in the specified field.
7. Complete the patient's address, including city, state, and zip code.
8. If applicable, fill in the Referring provider number. This may not be necessary if no referral was made.
9. Indicate if radiographs are attached and specify the number of attached radiographs, if any.
10. Note other attachments, if relevant, in the provided section.
11. Indicate whether the treatment was related to an accident or injury, especially if employment-related.
12. Mark if eligibility is pending to signify pending coverage verification.
13. Disclose if there are any other dental coverages besides Medi-Cal.
14. If applicable, indicate whether the patient has Medicare dental coverage.
15. Specify if retroactive eligibility applies to this claim.
16. Mention the CHDP, which stands for Child Health and Disability Prevention, if applicable.
17. Indicate if the California Children Services (CCS) program is involved.
18. If Maxillofacial-Orthodontic Services were utilized, provide the necessary details.
19. Complete the billing provider's name in Last, First, and Middle initial format.
20. Enter the Medi-Cal provider number associated with the billing entity.
21. Fill the mailing address information; use the practice address on the insurance forms where applicable.
22. Define the place of service, detailing where dental services were provided.
23. Input the Tooth number or letter arch related to the dental service performed.
24. Specify the surfaces involved with the dental treatment in the appropriate field.
25. Provide a brief description of the service rendered for clarity.
26. Enter the date the service was performed; leave blank if pre-authorization was required.
27. Indicate the fee charged for the service.
28. Enter the treating Medi-Cal provider number associated with the service.
29. Add any pertinent comments for specific considerations regarding the claim.
30. Calculate and enter the total fee charged for the services rendered.
31. Specify the patient share-of-cost amount, if applicable.
32. Indicate any amounts from other coverage that may apply.
33. Confirm the provider's signature in the designated area.
34. After completing the form, be sure to save changes, and you may also download, print, or share the form as needed.

Start completing your Denti-cal Combination-tar Dc-217 Claim Form Specifications online today!