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Colonial life claim form This includes Employer and Attending Physician portions of the claim form. Signed by Print name Telephone Number Title Date Email Address Colonial Life products are underwritten by Colonial Life Accident Insurance Company for which Colonial Life is the marketing brand. However you may follow your Please check the activities of daily living that the patient is unable to perform Date s of office visit Last 3 Months How often do you see the patient Have you referred patient for other types of consultations Name and address of Specialist Dates of Hospitalization Last 3 months claim form. Signature of Physician Physician s Specialty Fax Number Tax ID or SSN Physician/Group Name Patient Account Number Do you accept Medical Records request by Fax Do you have authorization on file to release information to Colonial Life Was patient referred to you by another physician Provide the following information for referring doctor. Fax to Claims 1. 866. 887. 6644 From Number of pages Continuing Disability Claim Form Mail to P. O. BOX 100195 Columbia SC 29210 Questions Call 1. 800. 325. 4368 24 Hours A Day / 7 Days a Week Fax this direction* Do Not Use this Form if this is the first time you are filing for this injury or sickness If your name has changed please attach a copy of legal documentation i*e* marriage certificate or driver s license Section 1 TO BE COMPLETED BY POLICY OWNER Claimant name Mailing Address Male Female Birth Date Claimant Social Security Number Street or PO Box City State Apartment/Unit/Lot Number Zip Home telephone Policy owner e-mail address Work telephone Claim is for Accident Sickness Condition that keeps you from working Date the accident occurred not when it was treated Description of accident Were you at work at the time of your accident or sickness Yes No Dates unable to work To MM/DD/YYYY Have you been unable to perform any activities of daily living Yes No If yes please list the dates you were unable to perform the activities From To Check the activities that you are unable to perform dressing eating meal preparation toileting continence bathing transferring If not employed list dates of house confinement Date you returned to work House Confinement means you are kept at home by your condition* At Home means in your house or yard. However you may follow your doctor s orders even if it means leaving home. Full-time Part-time/Hours worked per week Dates employee unable to work Full-time Was employee at work when the accident or sickness occurred Date returned to work Employee job title Expected return to work Who should we contact for updates on return to work status Name/Phone/Email FRAUD NOTICE Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties. 10/12-Visit us online at Coloniallife. com 46988-20 Claim Fraud Statements For your protection the laws of several states including Alaska Arkansas Delaware Idaho Indiana Louisiana Minnesota New Hampshire Ohio Oklahoma and others require the following statement to appear on this claim form* Fraud Warning Any person who knowingly and with intent to injure defraud or deceive an insurance company files a statement of claim containing any false incomplete or misleading information is guilty of insurance fraud which is a felony.

Mvp claim adjustment request f... CLAIM ADJUSTMENT REQUEST FORM Please attach a copy of this completed form when returning claims to MVP Health Care for adjustments. Check the box that best describes the purpose for submitting the Claim Adjustment Request Form and attachments. If you have questions on completing this form please call Provider Claims Services at 800 684-9286. West Region Rochester and Buffalo should call Provider Services at 585 325-3114 or 800 999-3920 THIS FORM IS NOT REQUIRED FOR THE FOLLOWING APPEALS No Authorization / Pre-Certification obtained PRIOR to service Medical Necessity Inpatient Hospital Mailing addresses for Appeals are at www. mvphealthcare. com on the Contacting MVP resource Today s Date Please submit one claim per adjustment form and do not highlight any fields on this form or any attachments. An asterisk denotes required information* Document claim Member ID Date of Service Provider Name Member Name Contact Name Provider ID Tax ID Contact Phone Coordination of Benefits Information Contact Fax 1. Alternate Insurance Information/EOB Coverage Attached 2. No-Fault /Workers Comp Information/EOB Attached 3. COB Related Adjustment 7. Transportation Run Record Requested Documentation Enclosed 1. Surgical or Surgical Modifier 4. Path/Rad Findings 8. Manufacturer s Invoice 2. Office Notes 5. Code Review/Asst. Surg* 9. Medical Record Review 3. Surgical/Operative Reports 6. Follow-up Days 10. Evidence of Qualifying Stay 11. Second Level Clinical Review Check Reason for Adjustment Request please check only one Options 1-8 require a corrected UB-92 or CMS-1500 to be attached showing all charges 1. Added/Deleted Charges 8. Copay/Deductible/Coinsurance Adjustment 9. Timely Filing Issue 3. Diagnosis Correction 10. Duplicate Denial Error 4. CPT/Modifier Correction 11. Implant/High Cost Drug Invoice Attached 5. ICD-9 Procedure UB92-Box 80 Correction 12. Provider Information Correction 6. Place of Service Correction 13. Referral or Pre-Auth Now on file- 7. Quantity Correction Please note reason for adjustment untimely filing or rationale for modifier use Please return this completed form and any supporting documentation to MVP Health Care P. Check the box that best describes the purpose for submitting the Claim Adjustment Request Form and attachments. If you have questions on completing this form please call Provider Claims Services at 800 684-9286. If you have questions on completing this form please call Provider Claims Services at 800 684-9286. West Region Rochester and Buffalo should call Provider Services at 585 325-3114 or 800 999-3920 THIS FORM IS NOT REQUIRED FOR THE FOLLOWING APPEALS No Authorization / Pre-Certification obtained PRIOR to service Medical Necessity Inpatient Hospital Mailing addresses for Appeals are at www. West Region Rochester and Buffalo should call Provider Services at 585 325-3114 or 800 999-3920 THIS FORM IS NOT REQUIRED FOR THE FOLLOWING APPEALS No Authorization / Pre-Certification obtained PRIOR to service Medical Necessity Inpatient Hospital Mailing addresses for Appeals are at www. mvphealthcare. com on the Contacting MVP resource Today s Date Please submit one claim per adjustment form and do not highlight any fields on this form or any attachments.

Seven corners form INJURY AND ILLNESS PROOF OF LOSS FORM Seven Corners Inc. 303 Congressional Blvd. Carmel IN 46032 USA Phone 800 335-0477 or 317 575-2656 Fax 317-575-2256 800-335-0477 or 317-575-2656 Fax 317-575-2256 Print this Form scanned documents are accepted via e-mail to claims sevencorners. I agree that I will provide Seven Corners Inc. with any medical records or other records requested by Seven Corners Inc. to process the claim. I understand that my failure to provide requested documents to Seven Corners Inc. may result in denial of the claim. I understand that failure by any of the above referenced entities or individuals to provide information or documents to Seven Corners Inc. may result in denial of the claim. In addition I hereby certify that the above information is true and correct to the best of my knowledge and belief. I understand that any false statements made on this form or omissions of information requested by this form may result in denial of the claim. I acknowledge and understand the Fraud Notices on Page 3 of this document. Signature of Insured Optional for Insured s Convenience I further agree to allow Seven Corners to send copies of explanation of benefit forms copies of claim correspondence and other confidential medical. Pennsylvania Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or Tennessee Virginia Washington It is a crime to knowingly provide false incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment fines and denial of insurance benefits. Texas Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Claim Correspondence/Payment Instructions primary information Insured ID Patient correspondence information Yes No Yes Phone in the US Phone Outside of the US Address in the US address city state postal code Address Outside the US address city state postal code country payment information Payments to be sent to Bank account in the US No If yes provide Banking Information in section below bank information Bank s name Bank s Address address city state postal code country Bank s Phone Bank s Account Type of account Name on Account exactly as it appears on your bank statements IBAN Number and/or Swift Code required for wire transfers Bank currency for this account Bank routing/sort code Checks cannot be sent to Banks outside the United States Wire transfer for Banks outside the United States only Greater than 50. 00 USD Disclaimer II hereby authorize and request Seven Corners to mail any correspondence and/or payments to the above listed address. Penalties include imprisonment fines and denial of insurance benefits. Texas Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Claim Correspondence/Payment Instructions primary information Insured ID Patient correspondence information Yes No Yes Phone in the US Phone Outside of the US Address in the US address city state postal code Address Outside the US address city state postal code country payment information Payments to be sent to Bank account in the US No If yes provide Banking Information in section below bank information Bank s name Bank s Address address city state postal code country Bank s Phone Bank s Account Type of account Name on Account exactly as it appears on your bank statements IBAN Number and/or Swift Code required for wire transfers Bank currency for this account Bank routing/sort code Checks cannot be sent to Banks outside the United States Wire transfer for Banks outside the United States only Greater than 50. 00 USD Disclaimer II hereby authorize and request Seven Corners to mail any correspondence and/or payments to the above listed address. II further agree to release Seven Corners of any and liability in the the eventlostloststolen correspondence/payments. Penalties. coverage information Insurance Carrier Name of Group / Plan Coverage Effective Date month/day/year Coverage Termination Date month/day/year // Policy / Certificate Number insured information Name of Insured last first middle initial suffix claimant information Name of Claimant last first middle initial suffix Date of Birth month/day/year Sex M F current address Current Residence Address address city state postal code country permanent address Daytime Phone Number area and / or country code If Applicable Date scheduled to return to Home Country Email Address or N/A medical information If Injury provide details i.e. how when and where injury occurred If Illness advise when and where symptoms first occurred and nature of illness Name and address of Consulting or Treating Physicians Have you ever been treated for this Illness before Yes No If Yes when Provide Name and Address of your Primary Care Physician in your Home Country Indicate other Employer / Private / Government Medical Insurance coverage include name address policy number and certificate number of Insurer Please advise names of any prescription medications you are presently taking I the undersigned authorize any hospital or other medical-care institution physician or other medical professional pharmacy insurance support organization governmental agency group policyholder insurance company association employer relative or benefit plan administrator to furnish to Seven Corners Inc. any and all information with respect to any injury or illness suffered by the medical history of or any consultation prescription or treatment provided to the person whose death injury illness or loss is the basis of the claim and copies of all that person s hospital or medical records including information relating to mental illness and use of drugs and alcohol to determine eligibility for benefit payments under the policy identified above.

Shelter care claim form ShelterCare Claim Form www.sheltercare.com 1-877-707-7297 CHECkLIst NOTE: You must submit an itemized paid invoice with claim form. Please return the completed claim form with paid invoices and complete

Eyemed claim form Out-Of-Network Claim Form Most EyeMed Vision Care plans allow members the choice to visit an in-network or out-of-network vision care provider. Com EyeMed Vision Care Attn OON Claims P. O. Box 8504 Mason OH 45040-7111 Print Reset Fraud Warning Statements Arizona For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. If you choose an out-of-network provider please complete the following steps prior to submitting the claim form to EyeMed. Any missing or incomplete information may result in delay of payment or the form being returned. Please complete and send this form to EyeMed within 1 year from the original date of service at the out-of-network provider s office. 3. EyeMed will only accept itemized paid receipts that indicate the services provided and the amount charged for each service. The services must be paid in full in order to receive benefits. Handwritten receipts must be on the provider s letterhead. Attach itemized paid receipts from your provider to the claim form. If the paid receipt is not in US dollars please identify the currency in which the receipt was paid. 4. If it is later determined that the patient was not entitled to the reimbursement you agree to refund EyeMed in full. Please indicate to whom the reimbursement should be sent Subscriber Patient Sign the claim form where indicated. Date of Service Patient Information Last Name First Name MI Street Address City State Zip Phone Birth Date Plan Information Last First Plan Name Subscriber ID Request For Reimbursement Please Enter Amount Charged. Remember to include itemized paid receipts Exam Frames Lenses Contact Lenses includes fit and follow-up please submit all contact related charges at the same time If lenses were purchased please select type Single Bifocal Trifocal Progressive I hereby understand that without prior authorization form EyeMed Vision Care LLC for services rendered I may be denied reimbursement for submitted vision care services for which I am not eligible. EyeMed will reimburse you for authorized services according to your plan design. 2. Please complete all sections of this form to ensure proper benefit allocation. Plan information may be found on your benefit ID Card or via your human resources department. You only need to complete this form if you are visiting a provider that is not a participating provider on the EyeMed network. Not all plans have out-of-network benefits so please consult your member benefits information to ensure coverage of services and/or materials from non-participating providers. 1. When visiting an out-of-network provider you are responsible for payment of services and/or materials at the time of service. 3. EyeMed will only accept itemized paid receipts that indicate the services provided and the amount charged for each service. The services must be paid in full in order to receive benefits. Handwritten receipts must be on the provider s letterhead* Attach itemized paid receipts from your provider to the claim form* If the paid receipt is not in US dollars please identify the currency in which the receipt was paid* 4.

Sun lifeca pshcp form Public Service Health Care Plan (PSHCP) Claim Form Out-of-Country Claims (Comprehensive Coverage) The PSHCP is administered by Sun Life Assurance Companie of Canada, a member of the Sun Life Financial

Claim form for claim against c... CLAIM AGAINST THE COUNTY OF STANISLAUS (Government Code Section 910.et seq.) Claimants: Name SSN# Date of Birth Address Phone Number Name, address and phone number of person to receive notices concerning

Orange county ca fillable smal... SMALL CLAIMS BOOKLET HOW TO FILE AND SERVE A SMALL CLAIMS CASE SUPERIOR COURT OF CALIFORNIA COUNTY OF ORANGE To open a Small Claims Case, refer to and fill out the following: Information for Plaintiff

04 form NUBC National Uniform Billing Committee LIC9213257 QUAL FIRST THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. Green Required/Preferred Black Situational/Required if Applicable/Reserved 80 REMARKS H Q SAMPLE OUTPATIENT UB-04 FORM. New UB-04 Form Instructions The Office of Management and Budget OMB and the National Uniform Billing Committee NUBC previously approved the UB-04 claim form also known as the CMS-1450 form. The UB-04 claim form accommodates the National Provider Identifier NPI and incorporated other important changes. SAMPLE INPATIENT UB-04 FORM 3a PAT. CNTL b. MED. REC. 5 FED. TAX NO. 8 PATIENT NAME 9 PATIENT ADDRESS a 11 SEX OCCURRENCE CODE DATE c ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT TYPE OF BILL STATEMENT COVERS PERIOD FROM THROUGH b 10 BIRTHDATE CONDITION CODES d e 29 ACDT 30 STATE VALUE CODES AMOUNT 42 REV. The UB-04 form has been used exclusively for institutional billing beginning May 23 2007. Sample UB-04 forms for inpatient and outpatient services are enclosed. The UB-04 Claim Form and NPI NPI you must continue to report your current provider identification numbers in the appropriate areas of the form. UB-04 Data Field Requirements FIELD LOCATION UB-04 DESCRIPTION INPATIENT OUTPATIENT Provider Name and Address Required Pay-To Name and Address Situational 3a Patient Control Number 3b Medical Record Number Type of Bill Federal Tax Number Statement Covers Period Future Use N/A 8a Patient ID 8b Patient Name Patient Address Patient Birthdate Patient Sex Admission Date Admission Hour Type of Admission/Visit Source of Admission Discharge Hour Patient Discharge Status 18-28 Condition Codes Required if Applicable Accident State 31-34 Occurrence Code and Dates 35-36 Occurrence Span Codes and Dates Subscriber Name and Address 39-41 Value Codes and Amounts Revenue Code HCPCS/Rates For additional information on the completion of fields please refer to the NUBC Official UB-04 Data Specifications Manual. 2012 PASSPORT HEALTH PLAN PA-111378 Service Date Units of Service Total Charges By Rev. Code Non-Covered Charges Payer Identification Name NPI Release of Info Certification Assignment of Benefit Certification Prior Payments Estimated Amount Due Health Plan IDs Insured s Name Patient s Relation to the Insured Insured s Unique ID Insured Group Name Treatment Authorization Codes Document Control Number Employer Name Diagnosis/Procedure Code Qualifier Principal Diagnosis Code/Other Diagnosis Codes Admitting Diagnosis Code Patient s Reason for Visit Code PPS Code External Cause of Injury Code Principal Procedure Code/Date Attending Name/ ID-Qualifier Operating ID 78-79 Other ID Remarks Code-Code Field/Qualifiers 0-A0 A1-A4 A5-B0 B1-B2 B3 We would also like to remind you of the requirements for electronic transactions. As a reminder Passport Health Plan strongly recommends the continued use of plan identification numbers in addition to NPI. This form replaced the UB-92 claim form and was phased in over a transition period beginning March 1 2007. The UB-04 form has been used exclusively for institutional billing beginning May 23 2007. Sample UB-04 forms for inpatient and outpatient services are enclosed. The UB-04 Claim Form and NPI NPI you must continue to report your current provider identification numbers in the appropriate areas of the form. UB-04 Data Field Requirements FIELD LOCATION UB-04 DESCRIPTION INPATIENT OUTPATIENT Provider Name and Address Required Pay-To Name and Address Situational 3a Patient Control Number 3b Medical Record Number Type of Bill Federal Tax Number Statement Covers Period Future Use N/A 8a Patient ID 8b Patient Name Patient Address Patient Birthdate Patient Sex Admission Date Admission Hour Type of Admission/Visit Source of Admission Discharge Hour Patient Discharge Status 18-28 Condition Codes Required if Applicable Accident State 31-34 Occurrence Code and Dates 35-36 Occurrence Span Codes and Dates Subscriber Name and Address 39-41 Value Codes and Amounts Revenue Code HCPCS/Rates For additional information on the completion of fields please refer to the NUBC Official UB-04 Data Specifications Manual. 2012 PASSPORT HEALTH PLAN PA-111378 Service Date Units of Service Total Charges By Rev. Code Non-Covered Charges Payer Identification Name NPI Release of Info Certification Assignment of Benefit Certification Prior Payments Estimated Amount Due Health Plan IDs Insured s Name Patient s Relation to the Insured Insured s Unique ID Insured Group Name Treatment Authorization Codes Document Control Number Employer Name Diagnosis/Procedure Code Qualifier Principal Diagnosis Code/Other Diagnosis Codes Admitting Diagnosis Code Patient s Reason for Visit Code PPS Code External Cause of Injury Code Principal Procedure Code/Date Attending Name/ ID-Qualifier Operating ID 78-79 Other ID Remarks Code-Code Field/Qualifiers 0-A0 A1-A4 A5-B0 B1-B2 B3 We would also like to remind you of the requirements for electronic transactions.

Claim lincoln form 2011 2019 Mail Completed Claims to The Lincoln National Life Insurance Company Dental Claims Processing Center PO Box 614008 Orlando FL 32861 Toll Free 800-423-2765 FAX 877-843-3945 DENTAL CLAIM FORM HEADER INFORMATION 1. Type of Transaction Check all applicable boxes h Statement of Actual Services h Request for Predetermination/Preauthorization h EPSDT / Title XIX 2. Predetermination/Preauthorization Number POLICYHOLDER / SUBSCRIBER INFORMATION INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION 12. Policyholder/Subscriber Name Last First Middle Initial Suffix Address City State ZIP For Insurance Company Named in 3 3. Company/Plan Name Address City State ZIP 13. Date of Birth MM/DD/CCYY 14. Gender hM hF OTHER COVERAGE 4. Other Dental or Medical Coverage h No Skip 5-11 h Yes Complete 5-11 16. Plan/Group Number 17. Employer Name 5. Name of Policyholder/Subscriber in 4 Last First Middle Initial Suffix PATIENT INFORMATION 19. Student Status h Self h Spouse h Dependent Child h Other h FTS h PTS 10. Patient s Relationship to Person Named in 5 20. Name Last First Middle Initial Suffix Address City State ZIP 11. Other Insurance Company/Dental Benefit Plan Name Address City State ZIP RECORD OF SERVICES PROVIDED 24. Procedure Date MM/DD/CCYY 25. Area of Oral Cavity 26. Tooth System 27. Tooth Number s 28. Tooth or Letter s Surface Code 30. Description 31. Fee MISSING TEETH INFORMATION 34. Place an X on each missing tooth Permanent Primary 2 3 4 5 6 7 8 10 11 12 13 14 15 16 A B C D E F G H I J 2 31 30 29 28 27 26 25 4 23 22 21 20 19 18 17 T S R Q P O N M L K 32. Other Fee s 33. Total Fee 35. Remarks AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION 36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan unless prohibited by law or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim* 38. Place of Treatment Check applicable box 39. Number of Enclosures 00 to 99 h Provider s Office h Hospital h ECF h Other Radiograph s Oral Image s Model s h 40. Is Treatment for Orthodontics 41. Date Appliance Placed MM/DD/CCYY h No Skip 41-42 h Yes Complete 41-42 42. Months of Treatment 43. Replacement of Prosthesis 44. Date Prior Placement Remaining h No h Yes Complete 44 X Patient/Guardian Signature Date 37. I hereby authorize and direct payment of the dental benefits otherwise payable to me directly to the below named dentist or dental entity. 45. Treatment Resulting from Check applicable box h Occupational illness/injury h Auto accident h Other accident 47. Auto Accident State 46. Date of Accident MM/DD/CCYY TREATING DENTIST AND TREATMENT LOCATION Subscriber Signature 53. I hereby certify that the procedures as indicated by date are in progress for procedures that require multiple visits or have been completed and that the fees submitted are the actual BILLING DENTIST OR DENTAL ENTITY Leave blank if dentist or dental entity fees I have charged and intend to collect for those procedures.

Ada dental claim form Adacatalog. org Comprehensive completion instructions for the ADA Dental Claim Form are found in Section 4 of the ADA Publication titled CDT-2007/2008. Wpc-edi. com/codes/taxonomy Should there be any updates to ADA Dental Claim Form completion instructions the updates will be posted on the ADA s web site at www. Name Address City State Zip Code 18. Relationship to Policyholder/Subscriber in 12 Above J400 Same as ADA Dental Claim Form J401 J402 J403 J404 To Reorder call 1-800-947-4746 or go online at www. Five relevant extracts from that section follow GENERAL INSTRUCTIONS A. The form is designed so that the name and address Item 3 of the third-party payer receiving the claim insurance company/dental benefit plan is visible in a standard 10 window envelope. Please fold the form using the tick-marks printed in the margin. B. In the upper-right of the form a blank space is provided for the convenience of the payer or insurance company to allow the assignment of a claim or control number. C. All Items in the form must be completed unless it is noted on the form or in the following instructions that completion is not required. D. Dental Claim Form HEADER INFORMATION 1. Type of Transaction Mark all applicable boxes Statement of Actual Services Request for Predetermination / Preauthorization EPSDT/ Title XIX POLICYHOLDER/SUBSCRIBER INFORMATION For Insurance Company Named in 3 2. Predetermination / Preauthorization Number 12. Policyholder/Subscriber Name Last First Middle Initial Suffix Address City State Zip Code INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION 3. Company/Plan Name Address City State Zip Code 14. Gender 13. Date of Birth MM/DD/CCYY M OTHER COVERAGE 16. Plan/Group Number 4. Other Dental or Medical Coverage F 17. Employer Name Yes Complete 5-11 No Skip 5-11 PATIENT INFORMATION 5. Name of Policyholder/Subscriber in 4 Last First Middle Initial Suffix Self Spouse Dependent Other 11. Other Insurance Company/Dental Benefit Plan Name Address City State Zip Code 22. Gender RECORD OF SERVICES PROVIDED 25. Area 26. of Oral Tooth Cavity System 28. Tooth Surface 27. Tooth Number s or Letter s 29. Procedure Code MISSING TEETH INFORMATION Permanent A B C D E G H I J 32. Other Fee s T S R Q P O N L K 33. Total Fee fold Primary 31. Fee Sa 34. Place an X on each missing tooth 30. Description m PTS 23. Patient ID/Account Assigned by Dentist FTS pl MM/DD/CCYY 19. Student Status Dependent Child 20. Name Last First Middle Initial Suffix Address City State Zip Code 10. Patient s Relationship to Person Named in 5 e 35. Remarks AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION 36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan unless prohibited by law or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim* 38.

2017 ada dental claim form HEADER INFORMATION Dental Claim Form Request for Predetermination / Preauthorization 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services EPSDT/ Title XIX 2. Predetermination

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