Get Ny Pba-14 2003-2026

Filling out the NY PBA-14 dental claim form online can streamline your submission process, ensuring that your claims are processed efficiently. This guide provides clear, step-by-step instructions to help you complete the form accurately.

Follow the steps to successfully complete your NY PBA-14 dental claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the member’s social security number in section 1. This identifier is necessary for processing your claim.
3. In section 2, provide the member’s full name including the last name, first name, and middle initial as applicable.
4. Fill out the member’s address in section 3, including the complete street address, city, state, and ZIP code.
5. In section 4 and section 5, input the patient's first and last names respectively. Ensure accuracy as this information corresponds to the care provided.
6. Specify the patient’s relationship to the member in section 6. Options include self, spouse, daughter, son, step-child, or other.
7. Record the patient’s date of birth in section 7. This date is crucial for verifying the patient’s eligibility.
8. In section 8, indicate whether the patient has other health and/or dental coverage by answering yes or no.
9. If the answer to section 8 is yes, provide additional information such as the policy holder’s name, social security number, employer or union name and address, and the name of the insurance carrier.
10. Sign the form in section 9. The member’s signature is necessary to process the claim. Note that the signature of a spouse or photocopy is not acceptable.
11. In sections 10 through 14, complete the dentist's information, including the dentist’s name, address, and tax identification number. Include their specialty and indicate missing teeth if applicable.
12. Document details about the dental services provided, including the description of services, date of service performed, procedure code, and fees in section 14.
13. Answer the questions in sections 15 through 18 about X-rays and prosthesis, providing necessary details as required.
14. Verify all information entered for accuracy and completeness before finalizing the form.
15. Once you have confirmed all entries, save changes, download, print, or share the completed form as needed.

Complete your dental claim form online today for a smoother submission process!