Dental Claim Form

Dental Claim

Provider information

Fields marked with an asterisk * are required.

Dentist first name *

Dentist last name *

Office address *

Office address 2

City *

5-digit ZIP Code *

Phone number 555-555-5555

Email address

name@email.com

NPI (National Provider Identifier) * 0123456789

TIN (Tax Identification Number) * 333-33-3333

Patient and subscriber information

Fields marked with an asterisk * are required.

Member search *

Member ID + DOB

First name + Last name + DOB

Member ID *

Date of birth *

mm/dd/yyyy

Patient first name *

Patient middle initial

Patient last name *

Patient date of birth *

mm/dd/yyyy

Member ID *

Donât include numbers after the dash or space in ID (use 1234567 instead of 1234567-00)

Group number *

Address *

Address 2

City *

5-digit ZIP Code *

Phone number 555-555-5555

If any additional/supplemental insurance was used to pay for any of this claim, add that information here.

Does the patient have additional insurance that applies to this claim? *

Yes

Claim information

To complete this section, you will need a copy of the patient's bill or statement. You may need to enter procedure codes, locations, and fees for service, which can be found on the bill. View the list of possible information you may need to file this claim.

Fields marked with an asterisk * are required.

What type of dental transaction was this? *

Statement of actual services

Predetermination/Preauthorization

Who should be reimbursed for this? *

Provider

Subscriber

Procedure(s)

Add dental procedures to this claim by adding the details below. *

Date of visit *

Su	Mo	Tu	We	Th	Fr	Sa
Javascript must be enabled

mm/dd/yyyy

Procedure code * Enter the 5-character procedure code that starts with 'D'

Description of procedure 250 characters remaining

Diagnosis code(s)

Use ICD-10 formatting to fill in the diagnosis code (e.g. S32.101A). Codes that start with 'D' are considered procedure codes.

Units *

Procedure fee *

Amount you are requesting for this claim

$0.00

Review and sign

1 Provider information

Dentist first name

Dentist last name

Office address

Office address 2

City

State

5-digit ZIP Code

Phone number

Email address

NPI (National Provider Identifier)

TIN (Tax Identification Number)

2 Patient and subscriber information

Results for "532861432"

Group number

1070520

Name	Member ID	Date of birth
LYNN WYATT	532861432	11/23/1969
CHRISTOPHER D WYATT	532861432	10/13/1999
ANNA M WYATT	532861432	11/18/2002
ALYSSA WYATT	532861432	05/29/1996
DONALD R WYATT	532861432	04/10/1965

Don't see the member you are looking for

CHRISTOPHER D WYATT

Group number

1070520

Date of birth

10/13/1999

Member ID

532861432

Address

1205 DONOVAN LN EVERETT, WA, 98201

Subscriber

Does the patient have additional insurance that applies to this claim? No

3 Claim information

What type of dental transaction was this? Predetermination/Preauthorization

Who should be reimbursed for this?

Amount you are requesting for this claim

Missing teeth

Other remarks

Does this claim include orthodontics? No

Does this claim include prosthesis (crown, bridge, or denture)? No

Does this claim relate to an accident/injury/illness?

4 Upload documents

Uploaded documents

Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

I certify that the procedures indicated on this form are either in progress or have been completed. I understand that by putting my name in the field below, I am signing this form electronically.

Provider acknowledgement *

The dentist or dental office has explained the dental treatment plan and costs to the patient or authorized representative. The office has a patient or authorized representative signature stating that the patient or authorized representative will be responsible for all charges for dental services and materials not paid by the patient's dental benefit plan, unless the charges are not allowed by law. The patient or authorized representative has also agreed in writing that the dentist or dental office can use and disclose the patient's protected health information in order to process this claim.

Payment acknowledgement *

The dentist or dental office has a signature on file of the patient or authorized representative allowing direct payment to the dentist or dental office.

Provider signature *

Today's date *

mm/dd/yyyy

-->

Dental Claim

Provider information

You have 0 fields that need to be corrected

Treating dentist details

Patient and subscriber information

You have 0 fields that need to be corrected

Patient information

You have field that need to be corrected

Additional insurance

Add subscriber insurance details

Add subscriber insurance details

Claim information

You have 0 fields that need to be corrected

Claim details

Procedure(s)

You have Add procedure field that need to be corrected

Add procedure

Additional claim information

Upload documents

You have 0 fields that need to be corrected

Uploaded documents

Review and sign

You have field that need to be corrected

1 Provider information

Treating dentist details

2 Patient and subscriber information

Patient information

You have field that need to be corrected

Additional insurance

Add subscriber insurance details

3 Claim information

Claim details

Additional claim information

4 Upload documents

Uploaded documents

Fraud Notice

Acknowledgements and signature

Dental Claim and Pre-treatment Estimate

Thank you

Confirmation details

Confirmation number
Submission date
Files attached	1

Dental Claim

Provider information

form errors You have 0 fields that need to be corrected

Treating dentist details

Patient and subscriber information

form errors You have 0 fields that need to be corrected

Patient information

form errors You have field that need to be corrected

Additional insurance

Add subscriber insurance details

Claim information

form errors You have 0 fields that need to be corrected

Claim details

form errors You have Add procedure field that need to be corrected

Add procedure

Additional claim information

Upload documents

form errors You have 0 fields that need to be corrected

Uploaded documents

Review and sign

form errors You have field that need to be corrected

1 Provider information

Treating dentist details

2 Patient and subscriber information

Patient information

form errors You have field that need to be corrected

Additional insurance

3 Claim information

Claim details

Additional claim information

4 Upload documents

Uploaded documents

Fraud Notice

Acknowledgements and signature

Dental Claim and Pre-treatment Estimate

Thank you

Confirmation details

You have 0 fields that need to be corrected

You have 0 fields that need to be corrected

You have field that need to be corrected

You have 0 fields that need to be corrected

You have Add procedure field that need to be corrected

You have 0 fields that need to be corrected

You have field that need to be corrected

You have field that need to be corrected