Type of transaction (check all applicable boxes) epsdt/title xix. • if you are covered by other dental coverage, attach a copy of the bills
Self spouse dependent child other 19.
Self insured dental services claim form. If you wish benefits to be paid directly to yourself. Signed (patient, or parent if minor) 12. Any updates to these instructions will be posted on the ada’s web site (ada.org).
Date of birth (mm/dd/ccyy) 22. Reserved for future use address, city, state, zip code 21. It is important that you discuss your treatment plan and charges with your dentist prior to starting any work.
Reserved for future use 21. You must sign the claim form in item 21. Dental care claim form note:
Insured's name (surname, first name, middle initial) date of birth 2. Comprehensive ada dental claim form completion instructions are printed in the cdt manual. Comprehensive ada dental claim form completion instructions are printed in the cdt manual.
Any updates to these instructions will be posted on the ada’s web site (ada.org). Used when other fees applicable to dental services provided must be recorded. Please do not fax bills to the above number.
Www.asonet.com dental claims must be filed within 12 months after the date of service. To the extent permitted under applicable law, i authorize release of any information relating to this claim. Charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or.
Fax the completed form to: Gender m f u 23. Or may choose any dentist and submit for reimbursement according to the uft welfare fund schedule of covered dental expenses.
Cx076 www.asonet.com claim forms are available from: Total of all fees listed on the claim form. Gender m f u 23.
Claims must be submitted within 3 months of being incurred to be eligible for reimbursement 1. Company/plan dentist or supplier patient/insured information d m y 3. Comprehensive ada dental claim form completion instructions are printed in the cdt manual.
Self spouse dependent child other 19. Date of birth (mm/dd/ccyy) 22. Be aware that the fund does not recommend or endorse any dentists.
Actual payment may differ from the estimate. Self insured dental services po box 9005, dept. Dental services and materials not paid by my dental benefit plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges.
Report missing teeth on each claim submission. Insured's address and telephone number 4. We cannot accept or process faxed bills.
Such fees include state taxes, where applicable, and other fees imposed by regulatory bodies. We would like to show you a description here but the site won’t allow us. Patient’ s relationship to other insured (check applicable box) self spouse dependent other primary insured information 12.
You can arrange for metlife to make payment directly to the dentist by completing item 22. You should exercise the same care and apply the same criteria in selecting a participating dentist that you would. Completing either of these forms creates a priority work item for the claim manager to review.