Get Chis/f03 - Estimate For Dental And Orthodontic Treatment And Prostheses. Form For Estimate For

Filling out the CHIS/F03 form is an essential step for obtaining approval for dental and orthodontic treatments under the CERN Health Insurance Scheme. This user-friendly guide provides a step-by-step approach to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the estimate form.

1. Click the ‘Get Form’ button to obtain the form and open it for completion.
2. Fill in the patient details section. Provide the full name and date of birth of the patient. Ensure you include the insurance number as well.
3. In the insured main member section, enter their full name. In cases where the patient is a minor, a legal guardian's signature is required. Ensure that you or the legal guardian sign the designated area.
4. Provide the dentist identification by including the stamp and signature of the treating dentist.
5. Attach the odontogram and X-ray of the tooth or teeth to be treated. Follow the instructions regarding marking any missing teeth or those that require extraction.
6. Complete the proposed treatment section. Indicate the tooth or teeth that are to be treated, the description of the work, the procedure code, and the estimated cost.
7. Enter the anticipated number of sessions that the treatment may require and include any comments from the dentist if applicable.
8. Review the validity period for the proposal. The default is six months, but this can be adjusted. Ensure that you check this information carefully.
9. Complete the prior opinion section, which includes obtaining the signature or stamp from UNIQA or the consulting dentist, along with the date.
10. Once the form is fully completed, save any changes and download the document. You may choose to print it out or share it as necessary.

Start filling out your estimate form online today to ensure timely processing of your dental treatment.