HomeMy WebLinkAboutDelta Dental claimDelta Dental Plan of Iowa
P.O. Box 919 • Ankeny, Iowa 50021-0919
ATTENDING DENTIST’S STATEMENT PATIENT ACCOUNT NUMBER
n PRETREATMENT REQUEST
PATIENT SECTION n SETTLEMENT OF ACTUAL SERVICES
1. PATIENT NAME (LAST) (FIRST) (INITIAL) 2. RELATIONSHIP TO SUBSCRIBER
n SELF n SPOUSE n DEPENDENT
3. SEX 4. PATIENT BIRTH DATE 5. IF FULLTIME STUDENT CITY STATE 7. SUBSCRIBER IDENTIFICATION NUMBER
MONTH DAY YEARnMnF
6. SUBSCRIBER NAME (LAST) (FIRST) (INITIAL) SUBSCRIBER HOME PHONE NUMBER SUBSCRIBER WORK PHONE NUMBER
( ) ( )
8. SUBSCRIBER ADDRESS (STREET OR RFD NUMBER, CITY, STATE, ZIPCODE) 9. EMPLOYER NAME AND ADDRESS (STREET, CITY, STATE, ZIP)
10. IS PATIENT COVERED BY DENTAL PLAN NAME UNION LOCAL GROUP NUMBER
ANOTHER DENTAL PLAN?n YES n NO
NAME AND ADDRESS OF OTHER INSURANCE COMPANY
I hereby accept the above treatment and authorize release of any information relating to this claim.
PATIENT/PARENT OR
EMPLOYEE-MEMBER SIGNATURE X DATE
DENTIST SECTION PLEASE PROVIDE TOOTH NUMBERS WHERE REQUIRED
11. DENTIST NAME 12. ADDRESS (STREET, CITY, STATE, ZIP) 16. IS TREATMENTA RESULT YES NO IF YES, ENTER BRIEF DESCRIPTION AND DATES
OF OCCUPATIONAL
INJURY?
17. IS TREATMENTA RESULT
OF AUTO ACCIDENT?
OTHER ACCIDENT?
13. TAX I.D. NUMBER 14. DENTIST LICENSE NUMBER 15. DENTIST PHONE NUMBER 18. IS TREATMENT FOR IF SERVICES DATE APPLIANCES PLACED MONTHS TREATMENT
ORTHODONTICS? ALREADY REMAINING
COMMENCED,
ENTER
DIAGNOSTIC AND TREATMENT RECORD ARE X-RAYS OR OTHER BENEFIT
LIST IN ORDER FROM TOOTH #1 THROUGH TOOTH #32 REVIEW DOCUMENTS ATTACHED?n YES n NO 19. PLACE OF TREATMENT n OFFICE n HOSPITAL n OTHER
TOOTH #COMPLETION DATE PROCEDURE
OR LETTER QUAD SURFACES DESCRIPTION OF SERVICE MONTH / DATE / YEAR CODE CHARGE
1.)
2.)
3.)
4.)
5.)
6.)
7.)
8.)
9.)
10.)
I hereby certify that the services listed above have been performed and to the best of my knowledge are within the provisions
of the plan, payment is therefore due.OUT OF STATE DENTISTS ONLY:TOTAL
ARE YOU A DELTA MEMBER?
DENTIST SIGNATURE X DATE n YES n NO LESS THIRD
IF YES, PLEASE PROVIDE TAX I.D. #PARTY PAYMENTS
NET CHARGE
PC-001 - 9/99
DENTAL CLAIM FORM