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Get ADA Dental Claim Form 2006.pdf

N / Preauthorization Number POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3) 12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION 3. Company/Plan Name, Address, City, State, Zip Code 15. Policyholder/Subscriber ID (SSN or ID#) 14. Gender 13. Date of Birth (MM/DD/CCYY) M OTHER COVERAGE 16. Plan/Group Number 4. Other Dental or Medical Coverage? F 17. Employer Name.

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