CONTINENTAL AMERICAN INSURANCE COMPANY Dental …
Dental Claim Form ©American Dental Association, 1999 version 2000 ©American Dental Association, 1999 1. Dentist’s pre-treatment estimate Dentist’s statement of actual services Specialty (see backside) 3. Carrier Name 2. Medicaid Claim 4. Carrier Address EPSDT Prior Authorization # 5. City 6. State 7. Zip 8. Patient First Name 9. Address ...
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SUPPLEMENTAL CLAIM FORM (CONTINUING DISABILITY)
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www.aflacgroupinsurance.comAny information obtained wil not be released by Continental America Insurance Company to any person or organization EXCEPT to re -insuring companies, or other person or organizatoi n performng business or legal services in connectoni with any
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www.aflacgroupinsurance.cominformation in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. California – For your protection California law requires the following to appear on this form: “Any person who knowingly presents …
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Insuring Over 40 Million People Worldwide
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