Transcription of 4 - PDF Claimforms HF004 Dental - Aflac
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4 - PDF Claimforms HF004 Dental - Aflac
08/19 INSTRUCTIONS FOR FILING Dental CLAIMSPLEASE DO NOT SUBMIT THIS FORMFOR DOES NOT REQUIRE PRECERTIFICATIONS AND WILL NOT COMPLETE THE ask your dentist s office to complete the entire form. Blank fields will cause the formto be returned and the claims processing to be delayed. We must have the followinginformation: The policyholder s Dental policy number (please leave the Group field blank). The policyholder s complete name as it is printed on the Dental plan ID card. The patient s full name, sex, date of birth and relationship to the insured. The treatment date, tooth or surface repaired, oral cavity, and if initial placement, the ADA codeand charge for each procedure. The patient s Social Security number(to speed up claims processing).
04/05 instructionsforfilingdentalclaims pleasedonotsubmitthisformforprecertification. aflacdoesnotrequireprecertificationsandwillnotcompletetheformfor
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