PTE Form
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Provider Information

  • Dentist Name:
  • Phone:
  • Email:
  • NPI:
  • TIN:

Patient Information

  • Name:
  • DOB:
  • Group Number:
  • Member ID:

Additional Insurance

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

If the patient has an EOB (Explanation of Benefits) for this dental/medical visit, it will need to be added to this claim. Instructions on how to add the EOB are in the final section of this form.

Procedure

Please enter a billed amount for items below.

Procedure Decscription Unit Tooth Number Exception Code

Additional PTE Information

250  characters remaining

Upload Documents

To ensure timely processing of this PTE, please upload documents associated with the patient's procedure(s).

You may need the patients:

  • Peridontal Chart(s) or X-rays
  • Charting notes
  • Billing Statement
  • Explanation of Benefits (EOB) from additional insurance, if applicable
Documents remaining:
20/20
Upload space remaining:
20MB/20MB
Accepted file formats:
.pdf, .png, .jpg, .txt, .rtf, .tif, .bmp, .tiff