Transcription of D leM K D II DENTAL FORM Yes -Spouse/Domestic Partner D …
1 LeMKDENTALFORM~UFTumroFEOERATD!IOfTEACti ERSWElFARERRtDlQO, :EfICAIlFroEMTDHOf~AA.:O<lDDDDDR eferCompletedClaimsandQuestionsto: ,TN37422-75311-800-577-0576 IICIGNAH caltbCareQPRE-TREATMENTESTIMATE(REQUIRED FORINlAYS, ,BRIDGES, $500 INA90 DAYPERIOD)oPAYMENTCLAIMPLEASESUBMITPRE-T REATMENTX-AAVSFORNON-ROunNEEXTRACTIONSAN DPRE-ANDPOST Spouse/DomesticPartneris a (PleasePrint)IBirt~dateIISexIsoc;alse~ri tyiIIIIIHomeAddressCityStateZipCodeTelep hone#()SchoolorBureauISchoolTelephone# {)DYes0 NoNameandAddressofOtherCompany/Organizat ionProvidingDentalBenefitsunderwhichyoua recoveredPATIENTINFORMATIONP atientName(PleasePrint)RelationshiptoMem berSPOUSE/DOMESTICPARTNERINFORMATION-(Re quiredifclaimisforSpouse/DomesticPartner orDependentChild)Spouse/DomesticPartnerN ame(pleasePrint) ~otise/DomesticPartnerI ISpouselDomesticPartnerSocialSecurityII. }
2 8 Irthda!~.'IIIIIIIIIIIs spouse/domesticpartnercoveredbyanotherDe ntalBenefitsPlanotherthanUFTWF? #()AUTHORIZATION(Authorizationtoreleasei nformationmustbesignedorpaymentwillnotbe made)ToReleaseInformation:Ihavereviewedt hefollowing (PatientorParentif Minor) invalidunlesstheTAX10# (Member)DateDENTISTINFORMATION- (Seeinstructionsonthebackregardingthenee dforx-rays)Dentist'sName(pleasePrint)IUc ense#Taxpayer10 IIStreetAddressCityStateZipCodeTelephone II()FeeProcedureCodeAccidentInjury0 Yes0 NoMotorVehicleInjury0 Yes0 NoAGE:DateofPriorPlacementDateServicePer formed115thisclaimtheresultof:Descriptio nofService(includingmaterialsused)Surtac eTooth#orletter(((DENOTEMISSINGTEETHWITH AN"X"Areradiographsenclosed?Ifyes,howman y?~DVesONol-----------------'----------- -----------iPATIENT'SNAMEI fprosthesis,is thistheinitialplacement?)))
3 OYes0 NoIf 'lrllAtmontIllitimlltlll!lnd/orproC(ld~r lllllilnd,ifeomplotod,thedliltelilofoomp letion!lllillitli!dllbov!i,WasIIpl'8>tl' llfttmentfilledbyllnotherprovldllr7 QYaCNoSigned{Dentist)OateTOTALFEECHARGED C -1259(5/13)~I1111111111l1li1111~II}
