1. 2. UMR PO Box 30541 Salt Lake City, UT 84130 …

1 31. Auto accident?PATIENTCOVERAGEBILLINGDENTIST5. Relation to insured22. Address of where payment should be remitted23. city , State, Zip24. Dentist Soc Sec or Dentist license Dentist phone First visit date28. Place of treatmentcurrent seriesOffice Hosp ECF Other32. Other accident?Yes(If no, reason for replacement)34. Date of priorplacementIf services alreadyDate appliancesMos. treatmentcommenced, enter:placedremaining30. Is treatment resultof occupationalillness or injury?33. If prosthesis, is thisinitial placement?29. RadiographsNoYesIf yes, enter brief description and dates35. Is treatment fororthodontics?HowMany?No41. Total FeeCharged36. Identify missing teeth with "X"37. Examination and treatment plan - List in order from tooth No. 1 through tooth No. 32 - Use charting system onlyToothNo. orletterSurfaceDescription of Service(including x-rays, prophylaxis, materials, etc.)Line ServicePerformedYYYYP rocedureNumberFeeMMDD40.

2 Address where treatment was performedZip38. Remarks for unusual servicesState39. I hereby certify that the procedures as indicated bydate have been completed and that the fees submittedare the actual fees I have charged and intend to collect for those procedures.( Treating Dentist )42. Payment byother planMax allowablePatient paysCarrier paysCarrier %DeductiblePage 1 See next page21. Name of Billing Dentist or Dental I hereby authroize payment of the dental benefits otherwise payable to me directly to thebelow named dental entity17-B. Employee/subscribersoc. sec. number11. Employee/subscriber birthdateMMDD YYYY8. If full time studentschoolcityIs patient covered by a medical plan?15-A. Name and address of carrier(s)7. Patient birthdateMMDD YYYY3. Carrier name and AddressPrior Authorization ID Name and address of employer15-B. Group No.(s)otherMedicaid Claimchild9. Employee/subscriber nameand mailing addressSigned (Employee/subscriber)10.

3 Employee/subscribersoc sec numberYesNo14. Is patient covered by another dental plan?If yes, complete Employee/subscriber name(if different than patient's)YesNo19. I have reviewed the following treatment plan and fees. I agree to be responsible for all charges fordental services and materials not paid by my dental benefit plan, unless the treating dentist or dentalpractice has a contractual agreement with my plan prohibiting all or a portion of such charges. To theextent permitted under applicable law, I authorize release of any information relating to this (Patient, or parent if minor)13. Group number12. Employer (company)name and address6. Sexmf11. Employee/subscriberbirthdateMMDD YYYY4. Patient Relationship to ID 's pre-treatment estimateDentist's statement of actual servicesLicense NumberCityDateCF0101 08-08 UMRPO Box 30541 salt lake city , UT 84130 -05411-800-826-9781 INSTRUCTIONS FOR COMPLETING THIS FORMPage 2 Last pagePlease check with your provider before completing this form.

4 UMR accepts dental claims electronically throughthe following clearinghouse:Envoy/Web MDPhone: 1-888-416-0673 Payer ID: 39026 Sending claims electronically eliminates the needfor paper forms and allows for faster and more accuratesubmission of your provider has questions regarding this process, they may contact Envoy/Web MD or call the UMR EDIunit at is an explanation to aid in completing the 'Patient Coverage' section of this 's of patient to the employee named in Box of of of school and city where located if patient is age 19 or older and a full-time 's name and address10. Employee's Social Security number11. Birthdate of employee12. Name of employee's employer13. Group number of employee's dental plan14. Question asking whether the patient has dental coverage through another plan other than the one named inBox 12 and whether the patient has coverage through a group medical plan15-A. Name and address of other dental or medical carrier15-B.

5 Group number of other dental or medical carrier16. Name and address of employer who provides the other dental or medical coverage17-A. Name of the employee who has the other dental or medical coverage17-B. Social Security number of employee named in Box 17-A17-C. Birthdate of employee named in Box 17-A18. Relationship of patient to employee named in Box 17-A