Get Delta 105 #49481 2008-2026

Filling out the Delta 105 #49481 form is an essential step in ensuring that dental claims are submitted accurately and efficiently. This guide will walk you through the process of completing this form online, providing clear instructions for each section to help you submit your claims without any issues.

Follow the steps to complete the Delta 105 #49481 form successfully:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient name in the designated field. This should include the first, middle, and last name of the patient receiving dental treatment.
3. In the ‘Relationship to subscriber’ section, select the appropriate option that describes the relationship of the patient to the subscriber: Self, Spouse, Child, or Other.
4. Fill in the patient’s sex by selecting either Male or Female from the provided options.
5. Enter the patient’s birthdate in the format of Month, Day, and Year.
6. If the patient is a full-time student aged over 18, input their school name and city in the respective fields.
7. In the ‘Subscriber ID Number’ field, enter the identification number associated with the subscriber.
8. Provide the subscriber’s birthdate in the same Month, Day, Year format.
9. Input the employer’s name and address in the applicable section, ensuring all fields are filled out completely.
10. Confirm if the patient has coverage through another company. If yes, complete items 12 through 15.
11. If applicable, provide the name and address of any other dental carrier.
12. Fill in the subscriber name if it is different from the patient's name, along with the subscriber ID number.
13. Include the group number associated with the subscriber's plan.
14. Indicate the name and address of the employer related to the alternate dental carrier if applicable.
15. Complete other sections regarding previous treatment dates, services rendered, and any accidents related to the dental treatment.
16. In the final steps, ensure all fields are filled and review your information for accuracy. Once satisfied, save your changes, download, print, or share the form as needed.

Complete your Delta 105 #49481 form online today for efficient dental claim submission.