Follow the steps to accurately complete the form

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. In the first section, check the appropriate box to indicate whether you are submitting a dentist's pre-treatment estimate or a statement of actual services.
3. Fill out the patient details including their full name, birth date, relationship to the employee (self, child, spouse, or domestic partner), and sex.
4. Provide the employee's name, birth date, and social security or identification number, which may differ from the patient's details.
5. Indicate whether the patient is covered by another dental plan by checking 'Yes' or 'No' and provide the name and address of the other carrier if applicable.
6. Complete the sections regarding treatment information, which include the billing dentist's details, place of treatment, and any special remarks regarding services provided.
7. List all procedures performed by tooth number using the specified charting system, including detailed descriptions and dates.
8. Sign the form to authorize the release of information related to the claim and confirm your responsibility for the costs of dental treatment.
9. Once all sections are completed, review the form for accuracy, then save your changes, and prepare to print or share the form as needed.

Complete your dental claims process online today!