Transcription of 590154f Dental Claim Form Cigna
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590154f Dental Claim Form Cigna
RECORD OF SERVICES PROVIDED24. Procedure Date (MM/DD/CCYY)25. Area of Oral Cavity26. Tooth System 27. Tooth Number(s) or Letter(s)28. Tooth Surface29. Procedure Code29a. Diag. Pointer29b. Description31. Fee1234567891033. Missing Teeth Information (Place an X on each missing tooth.)34. Diagnosis Code List Qualifier ( ICD-9 = B; ICD-10 = AB ) 31a. Other Fee(s) 123456789 1011121314151634a. Diagnosis Code(s)A _____C _____32313029282726252423222120191817(Pr imary diagnosis in A )B _____D _____ 32. Total Fee 35. RemarksAUTHORIZATIONSANCILLARY Claim /TREATMENT INFORMATION36. 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.
The following information highlights certain form completion instructions. 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).
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