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.
To the extent permitted by law, I consent to your use and disclosure of ... A dentist is a person qualified by a doctorate in dental surgery (D.D.S.) or dental medicine (D.M.D.) licensed by the state to practice dentistry, ... Oral & Maxillofacial Radiology. 1223D0008X
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