Get CA Delta Dental Claim Form 2013

TRICARE Retiree Dental Program SEND DOMESTIC CLAIMS TO Federal Government Programs Po Box 537007 Sacramento CA 95853-7007 Claim Form SEND OVERSEAS CLAIMS TO United States of America Subscriber information 10 name last first mi and address pre-determination request statement of completed services 11 PHONE NUMBER INCLUDING COUNTRY CITY AND/OR AREA CODE 2 is patient covered by another dental/medical plan no skip 3-9 14 gender yes m 3 name of employee/policyholder last first mi 4 date of birth mm/dd/yyyy 5 gender 6 employee ssn/id Patient information f 16 patient name last first mi and address if different than primary enrollee 7 relationship to patient spouse 15 SUBSCRIBER IDENTIFICATION number self 12 EMAIL ADDRESS 13 DATE OF BIRTH MM/DD/YYYY Other coverage dependent other 8a group number of other carrier 8b amount paid group by other carrier 9 name and address of other carrier 18 if full-time student list school and city 20 gender Dental services 21 treatment plan list in order from tooth no. 1 through tooth no. 32 using the charting system shown below tooth guide tooth number or letter tooth surface description date of service mm/dd/yyyy cdt procedure code fee charged 22 INDICATE CURRENCY total fees charged 23 remarks for unusual services IMPORTANT FOR OVERSEAS CLAIMS ATTACH THE DENTIST S RECEIPT FOR COMPLETED SERVICES OR STATEMENT FOR PREDETERMINATION* Authorizations Treating dentist 29 dentist name and address i have reviewed the treatment plan and agree to be responsible for all charges for dental services not paid by my dental benefit plan unless the treating dentist has a contractual agreement with my plan prohibiting all or a portion of such charges. i consent to your use and disclosure of my protected health information and authorize release of any information relating to this claim* X signature of patient or parent/guardian date i hereby authorize and direct payment of the dental benefits otherwise payable to me directly to the named dentist or dental entity. signaure of primary enrollee 30 license number 31 tin or ssn 32 type-1 npi individual i hereby certify that the procedures listed by date are in progress for procedures that require multiple visits or have been completed* signature of dentist Billing dentist or dental entity leave this section blank if dentist or dental entity is not submitting this claim 26 dentist or dental entity name and address Additional claim information 34 radiographs enclosed no 35 replacement of prosthesis yes date of prior placement 36 treatment resulting from occupational illness/injury auto accident other accident 27 tin 28 type-2 npi organizational 37 treatment related to orthodontics TRDP Claim Form - 11/13 date appliance placed total months of treatment. 1 through tooth no. 32 using the charting system shown below tooth guide tooth number or letter tooth surface description date of service mm/dd/yyyy cdt procedure code fee charged 22 INDICATE CURRENCY total fees charged 23 remarks for unusual services IMPORTANT FOR OVERSEAS CLAIMS ATTACH THE DENTIST S RECEIPT FOR COMPLETED SERVICES OR STATEMENT FOR PREDETERMINATION* Authorizations Treating dentist 29 dentist name and address i have reviewed the treatment plan and agree to be responsible for all charges for dental services not paid by my dental benefit plan unless the treating dentist has a contractual agreement with my plan prohibiting all or a portion of such charges. i consent to your use and disclosure of my protected health information and authorize release of any information relating to this claim* X signature of patient or parent/guardian date i hereby authorize and direct payment of the dental benefits otherwise payable to me directly to the named dentist or dental entity. .