Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin by filling in your employee name and social security number in the designated fields at the top of the form.
3. Next, indicate who verified your eligibility by entering their name in the corresponding field.
4. Provide your complete address, including city, state or province, and ZIP code.
5. If the patient is a dependent, fill in their name in the patient name field, and specify the relationship to the employee.
6. Enter the patient's date of birth in the format requested.
7. Complete the employer name and group number sections with the necessary details.
8. Indicate if the patient is a student and if they have other dental coverage. If yes, provide the pertinent details.
9. Fill in the group dental plan name and plan number as required.
10. Enter the dentist's name, address, and license number accurately.
11. Affirm whether any treatment details pertain to orthodontic purposes, accidental injury, or occupational injury.
12. If applicable, state if the treatment is for an initial placement of a prosthesis or the reason for replacement.
13. Indicate whether x-rays are enclosed and specify the number if applicable.
14. Detail the examination and treatment records, including tooth numbers or letters, surfaces, services rendered, and dates of service.
15. Complete the section for unusual services and indicate any missing teeth.
16. Sign and date the form to authorize the release of information regarding the claim.
17. The dentist must sign to certify the listed services.
18. Lastly, authorize payment to the dentist and indicate your financial responsibility for any non-covered charges before finalizing the form.
19. Once you have filled out all sections, review the information for accuracy. Save any changes made to the form before proceeding to download, print, or share as needed.

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