4 - PDF Claimforms HF004 Dental - Aflac

1 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).

2 2. If the patient is a dependent under age 26, please indicate this status on the If you are filing for the initial benefit under the Orthodontic Rider or for a benefit under a cosmeticrider, there is a two-year waiting period before benefits are payable under these Your dentist may submit the claimelectronically. Make sure that Aflac s payer number (58066) isincluded on each the claimformdirectly to Aflac at: Aflac Worldwide HeadquartersAttention: Claims Department1932 Wynnton RoadColumbus, GA 31999-7254 Fax: ( ) Attn: Dental ClaimsHF004 PATIENTSUBSCRIBER/EMPLOYEE19. Subs. SSN #20. Employer Name21. Policy #22. Subscriber/Employee Name (Last, First, Middle)23. Address24. Phone Number()25. City26. State27.

3 Zip Code28. Date of Birth (MM/DD/YYYY)____/_____/_____29. Marital StatusoMarriedoSingleoOther30. SexoMoF39. I have been informed of the treatment plan and associated fees. I agree to beresponsible for all charges for Dental services and materials not paid by my dentalbenefit plan, unless the treating dentist or Dental practice has a contractual agreementwith my plan prohibiting all or a portion of such _____Signed (Patient/Guardian)Date: (MM/DD/YYYY)OTHERPOLICIESBILLINGDENTIST4 2. Name of Billing Dentist or Dental Entity43. Phone Number()44. Provider ID #45. Dentist Soc. Sec. or Address47. Dentist License #48. First visit date of current series:49. Place of City51. State52. Zip Code53. Radiographs or models enclosed?

4 OYes, How many?_____oNo54. Is treatment for orthodontics?oYesoNoIf service already commenced:55. If prosthesis (crown, bridge, dentures), isIf no, reason for replacement:Date of prior placement:this initial placement?oYesoNo_____Date appliances placedTotal months of treatment_____remaining: _____56. Is treatment result of occupational illness or injury?oNooYesBrief description and dates:_____57. Is treatment result of:oAuto Accident?oOther Accident?oNeitherBrief description and dates:_____61. Remarks for unusual services:Admin. Use Only04/058. Patient Name (Last, First, MIddle)9. Address10. City11. State12. Date of Birth (MM/DD/YYYY)____/_____/_____13. Patient ID # / SSN #14. Number()16. Zip to Subscriber / Employee:oSelfoSpouseoChildoOther / SchoolName: _____Address: _____31.

5 Is patient covered by another planoNo (Skip 32-37)oYesoDental oroMedical32. Policy #33. Other Subscriber's Name34. Date of Birth (MM/DD/YYYY)_____/_____/____35. SexoMoF36. Plan/Program Name37. Employer / SchoolName: _____Address_____38. Subscriber/Employee StatusoEmployedoPart-time StatusoFull-time StudentoPart-time Student40. Employer/SchoolName _____Address_____41. I hereby authorize payment of the Dental benefits otherwise payable to medirectly to the below named Dental _____Signed (Employee/ Subscriber)Date (MM/DD/YYYY)58. Diagnosis Code Index (optional)1. _____2. _____3. _____4. _____5. _____6. _____7. _____8. _____59. Examination and treatment plans. List teeth in (MM/DD/YYYY)ToothSurfaceDiagnosis Index #Procedure CodeQtyDescriptionFee60.

6 Identify all missing teeth with XPermanentPrimaryTotal Fee12345678910111213141516 ABCDEFGHIJP ayment by other plan32 31 30 29 28 27 26 2524 23222120191817 TSRQPONMLKMax. allowableDeductibleCarrier %Carrier paysPatient pays62. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) orhave been completed and that the fees submitted are the actual fees I have charged and intend to collect for _____Signed (Treating Dentist)License #Date (MM/DD/YYYY)63. Address where treatment was City65. State66. Zip 's pre-treatment estimateSpecialty (see backside)oDentist's statement of actual services3. Carrier ClaimoEPSDTP rior Authorization #4. Carrier Address5.

7 City6. State7. Ziprev. 5/16 Claims Authorization to Obtain InformationInstructions for completing this Health Insurance Portability and Accountability Act of 1996(HIPAA) compliant areas of this formshould be formmust be signed and dated by the claimant/patient : If you are filing a claimon behalf of a deceased, please check here you are the Authorized Representative, please sign below and indicate your relationship to theclaimant/patient/deceased. In addition, include a copy of the legal document(s) authorizing you toact on their this formto 1-877-442-3522 or return the formto Aflac , Attn: Claims Department, WorldwideHeadquarters, 1932 Wynnton Road, Columbus, GA 31999, as soon as possible in order to Name:Policy Number(s):Date of Birth:Policyholder Address:Claimant/Patient Name (if different fromnamed policyholder listed above):Date of Birth.

8 American Family Life Assurance Company of Columbus ( Aflac )Worldwide Headquarters 1932 Wynnton Road Columbus, Georgia 319991-800-992-3522 of claimant/patient, guardian or authorized representativeDatePrinted name of claimant/patient, guardian or authorized representativeRelationshipI understand health information may include information and records protected under Federal and State Lawsuch as: alcohol, drug abuse, mental health, AIDS or HIV testing or treatment, or the presence of acommunicable or noncommunicable treatment, payment or eligibility for benefits may not be conditioned on signing this understand that I may revoke this authorization at any time by writing toAflac, Claims Department,Worldwide Headquarters, 1932 Wynnton Road, Columbus, GA 31999, except to the extent has taken action in reliance to this authorization, law provides Aflac with the right to contest a claimunder the policy or the policy the requestor or receiver is not a health plan or health care provider.

9 The released information may nolonger be protected by federal privacy regulations and may be is recommended I retain a copy of this signed formfor my records, understanding that a copy is as validas the residents of AZ, CA, CT, GA, IL, ME, MA, MN, NV,NJ, NM, NC, OH, and VA,this authorization will be validfor a period of two years fromthe sign date or until thetermination of the policy coverage, whichever is less,unless a lesser alternate expiration date is provided residents of all other States,this authorization will bevalid for a period of two years fromthe sign date, unless alesser alternate expiration date is provided Expiration Date:Name and Address of health care provider(s),company, or individual authorized to releasethe requested information:(this section will be completed by Aflac ):Purpose of Disclosure:Evaluate claims for benefitsduring the time this authorization is , or my authorized representative, request that information regarding my past, present, or future physical ormental health condition (excluding psychotherapy notes), employment, other insurance coverage, or any othernonmedical facts be released toAmerican Family Life Assurance Company of Columbus ( Aflac )or anyperson or entity acting on its part.

10 This could include, but is not limited to, any medical professional, medicalcare institution, insurer (including Aflac , with respect to other Aflac coverages), reinsurer, government agency(including departments of public safety and motor vehicle departments), consumer reporting agency oremployer.