Fill and Sign the Family Court Disclosure Affidavitpdffillercom Form

ATTENDING DENTIST'S STATEMENT FOR PREDETERMINATION CHECK ONE: 1. PATIENT NAME P A T I E N T Administered by Omega Administrators, Inc. P.O. Box 6560 • Sherwood, AR 72124 FOR PAYMENT 2. RELATIONSHIP TO MEMBER SELF SPOUSE DGHTR SON 3. M 6. EMPLOYEE/SUBSCRIBER NAME FIRST MIDDLE 7. EMPLOYEE/SUBSCRIBER ID LAST 8. EMPLOYEE/SUBSCRIBER MAILING ADDRESS 4. PATIENT BIRTHDATE OTHER MO DAY Customer Service: 877-999-2330 501-992-2340 5. STUDENT INFORMATION YEAR FULL TIME F 9. NAME OF GROUP DENTAL PROGRAM PARTTIME_ – SCHOOL TELEPHONE NUMBER 10. EMPLOYER (COMPANY) NAME AND ADDRESS CITY, STATE, ZIP S E C T I O N 11. GROUP NUMBER D E N T I S T 16. BILLING DENTIST/ENTITY 25. IS TREATMENT RESULT OF OCCUPATIONAL ILLNESS OR INJURY? 17. MAILING ADDRESS 26. IS TREATMENT RESULT OF AUTO ACCIDENT? 27. OTHER ACCIDENT? S E C T I O N 12. LOCATION (LOCAL) 13. ARE OTHER FAMILY MEMBERS EMPLOYED? EMPLOYEE NAME I.D. NO. BIRTH DATE 14. NAME AND ADDRESS OF EMPLOYER IN ITEM 13. 15. IS PATIENT COVERED BY ANOTHER DENTAL PLAN? DENTAL PLAN NAME UNION LOCAL GROUP NO. NAME AND ADDRESS OF CARRIER CITY, STATE, ZIP 18. Tax Identification No. 22. FIRST VISIT DATE CURRENT SERIES NO YES IF YES, ENTER BRIEF DESCRIPTION AND DATES 28. ARE ANY SERVICES COVERED BY ANOTHER PLAN? 19. Dentist License No. 23. PLACE OF TREATMENT OFFICE HOSP. DESCRIPTION ECF 20. National Provider ID OTHER 21. Dentist Phone No. 24. RADIOGRAPHS OR MODELS ENCLOSED? NO 29. IF PROSTHESIS OR SINGLE CROWN(S), IS THIS INITIAL PLACEMENT? YES ATTACH X-RAYS SECURELY DATE SERVICE TOOTH PERFORMED # OR SURFACE LETTER MO. DAY YEAR PROCEDURE NUMBER HOW 31. IS TREATMENT FOR ORTHODONTICS? MANY? FEE DESCRIPTION OF SERVICE (IF NO, REASON FOR REPLACEMENT) IF SERVICES ALREADY COMMENCED, ENTER 30. DATE OF PRIOR PLACEMENT DATE APPLIANCE PLACED DATE SERVICE TOOTH PERFORMED # OR SURFACE LETTER MO. DAY YEAR MOS. TREATMENT REMAINING PROCEDURE NUMBER FEE WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD, 32. REMARKS FOR UNUSUAL SERVICES OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. IDENTIFY MISSING TEETH WITH "X" FACIAL I have reviewed the following treatment plan and fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan. To the extent permitted under applicable law, I authorize release of any information relating to this claim. TOTAL FEES Signature on File SIGNED (PATIENT, OR PARENT IF MINOR) DATE I hereby authorize payment of the dental benefits otherwise payable to me directly to the below named entity. Signature on File SIGNED (EMPLOYEE/SUBSCRIBER) DATE I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures. SIGNED (TREATING DENTIST) MAIL ORIGINAL TO PLAN, RETAIN COPY FOR YOUR FILE. Form Number OME-01 LICENSE NUMBER DATE FACIAL