MetLife Dental Claim Form

Dental Expense Claim

To Be Completed by Employee (You must review the important statements on page 2 and sign where indicated before completing this section of the form.)

1. Patient First Name Middle Last

2. Relationship to Employee Self Spouse Child Other

3. Sex Male Female

4. Married Yes No

5. Patient Date of Birth

6. For Office Use

7. If Full Time Student (Age 19 or Over) City State

8. Employee Social Security / ID Number

9. If Disabled (Age 19 or Over) Yes No

10. Name of Group Dental Program

11. Employee First Name Middle Last

12. Employee Date of Birth

13. Office Phone (Area Code)

14. Employee Residence Mailing Address

15. City, State, Zip

16. Are other Family Members Employed? Yes No

Name Social Security / ID Number

17. Date of Birth

18. Name and Address of Employer for Item 16

19. Is Patient Covered by Another Dental Plan? Yes No

(If Yes, complete the following:) Group No. Name and Address of Carrier

To Be Completed by Dentist

23. Dentist Name 24. Mailing Address

City State Zip

25. Dentist Social Security Number or T.I.N. 26. Dentist License Number 27. Dentist Phone Number

28. First Visit Date Current Series 29. Place of Treatment Office Hospital ECF Other

30. Radiographs or Models Enclosed? Yes No How Many?

31. Is Treatment Result of Occupational Illness or Injury? Yes No

32. Is Treatment Result of Auto Accident? Yes No

33. Other Accident? Yes No

34. Are any Services Covered by Another Plan? Yes No

35. If Prosthesis, is this Initial Placement? Yes No

36. Date of Prior Replacement?

37. Is Treatment for Orthodontics? Yes No If Services Already Commenced, Enter Date Appliance Placed Months of Treatment Remaining

Dentist’s Pretreatment Estimate Statement of Actual Services (Be sure to sign below)*

38. Examination and Treatment Plan - List in Order From Tooth #1 through Tooth #32 (Use Charting System Shown)

39. I Hereby Certify That The Services Listed Above Will Be Have Been Performed     Signature of Dentist Date Total Fee Actually Charged

40. Address where treatment was performed City State Zip

Please Review Before Submitting Claim

Information for Employee
1. Complete your section of the claim form (items 1 through 21) in full to assure positive identification and prompt payment. Please print or type.
2. Patient Services. By signing item 20 the patient (or parent or other authorized representative) consents to the use and disclosure of information relating to the services provided by the dentist or health care professional for the purpose of treatment, payment or health care operation, including submission of a claim for dental benefits to a provider or administrator of dental benefits plans. This consent will be valid for as long as the patient is entitled to coverage under a dental plan. You are entitled to a copy of this consent. This consent may be revoked in writing delivered to your dentist or health care professional, but such revocation will not affect any action taken in reliance on this consent prior to revocation. Upon receipt of revocation or refusal to sign consent, your dentist or health care professional may decline to provide or continue treatment. If this consent is signed by the authorized representative of the patient, the relationship of the authorized representative must be provided in item 20.
3. You must sign item 21.
4. You can arrange for MetLife to make payment directly to the dentist by completing item 22. If you wish benefits to be paid directly to yourself, do not complete item 22. If item 22 is complete, a statement of benefits paid will be sent to you.
5. If total charges for the planned course of treatment are expected to be $300 or more, the form should be completed and submitted to MetLife prior to the commencement of the course of treatment or a pre-treatment estimate of benefits. MetLife will notify you of your benefits payable. (If you wish, a pre-treatment estimate may be requested for anticipated dental expenses of less than $300.)
6. If total charges for the planned course of treatment will be less than $300, the claim form should be completed when treatment is completed and mailed to the address shown below.
Dental Coverage is subject to specific limitations and exclusions. Please refer to your booklet for a description of covered services, schedule of benefits payment, limitations and exclusions.

Information for Attending Dentist

1. Benefits are payable in accordance with four Classes of Services. It is therefore important that a separate fee is indicated for each item of service performed.
2. If total charges for a course of treatment are expected to be $300 or more, check the box noted "Pre-treatment estimate" and complete items 23 through 39. The completed form should be sent to the address shown below prior to the commencement of the course of treatment. MetLife will review the claim (and any supplementary information required) and notify your patient of the benefits payable.
3. If the address where treatment was performed is different than the mailing address in item 24, complete item 40.
4. Generally, we do not request x-rays where standard filling materials are used. Pre-operative x-rays are requested only in connection with prosthetics, fixed bridgework, or cast restorations. Occasionally we may request x-rays that relate to other dental services.
5. In an effort to reduce your costs and inconvenience, we request your cooperation in submitting x-rays only in the above mentioned circumstances or when specifically requested. This will also enable us to expedite the processing of a pre-treatment estimate.
6. If authorized by the employee, benefit payments will be made directly to you.

Mail Completed form to:
MetLife Dental Claims
P.O. Box 981282
El Paso, TX 79998-1282

Employees: 1-800-942-0854
Dentists: 1-877-638-3379