Dental Claim Submission Form Instructions

To submit this form, users can opt for multiple submission methods. You may email the completed form to your insurance provider or fax it using the designated fax number provided on your policy. Additionally, many providers accept forms submitted through their online portal, or you can mail the form to the physical address of your insurance company.

Important dates related to this dental claim form include annual enrollment deadlines and claim submission cut-off dates for 2024 and 2025. Ensure to check your insurance provider for specific dates to avoid late submissions. Staying updated on these timelines is crucial for successful processing of your claims.

The purpose of this form is to facilitate the submission of insurance claims for dental services provided to patients. It serves as an official record of the treatment received and the patient's insurance details, allowing for accurate processing by the dental office and insurance provider. Completing this form correctly ensures that patients receive the appropriate coverage for their dental treatments.

• 1. Patient Name: The name of the patient requiring dental services.
• 2. Relationship to Patient: Indicates whether the enrollee is the patient, spouse, or child.
• 3. Primary Enrollee Name: Name of the primary insured individual.
• 4. Mailing Address: The current mailing address of the enrollee.
• 5. Employer Name and Address: Details about the enrollee’s employer.
• 6. Dentist Information: Name, license number, and contact details of the attending dentist.
• 7. Services Received: A section to list all dental treatments and services provided.
• 8. Signatures: Required signatures for consent and authorization of payment.
• 9. Important Notifications: Information regarding legal or essential claims-related notices.

Failing to submit this form correctly may result in delays or denials of insurance claims. It is crucial to provide all necessary information to avoid complications in coverage. Missing information could lead to financial burdens on the patient due to unpaid services.

• Claims Delays: Inaccurate or incomplete forms can lead to significant delays in processing claims.
• Increased Out-of-Pocket Costs: Without proper submission, patients may incur out-of-pocket expenses for treatments.
• Lack of Coverage: Failure to provide the necessary information may result in denied coverage by insurance companies.

• 1. Routine Check-ups: To file claims for routine dental visits.
• 2. Major Dental Procedures: For high-cost treatments that require insurance approval.
• 3. Accident Related Treatments: When seeking coverage for dental services resulting from an accident.
• 4. Orthodontic Services: For claiming orthodontic procedures covered by your plan.
• 5. Emergency Dental Care: To submit claims for unplanned dental emergencies.