Dental Claim Form - Aflac Group Insurance

1 Dental Claim form american Dental association , 1999 version 2000 american Dental association , s pre-treatment estimateDentist s statement of actual servicesSpecialty (see backside)3. Carrier Name4. Carrier ClaimEPSDTP rior Authorization #5. City6. State7. Zip8. Patient First Name 9. Address10. City11. State12. Date of Birth (MM/DD/YYYY)//13. Certificate #14. SexMF15. Phone Number( )16. Zip CodePATIENT17. Relationship to Certificateholder/Employee:SelfSpouseChi ldOther_____18. EmployerName_____ Address_____19. ID#/SSN#20. Employer Name21. Group #31. Is Patient covered by another planNo (Skip 32 37)Yes: Dental or Medical32. Certificate #22. Certificateholder/Employee Name (Last, First, Middle)33.

2 Other Certificateholder s Name23. Address24. Phone Number( )34. Date of Birth (MM/DD/YYYY)//35. SexMF36. Plan/Program Name25. City26. State27. Zip CodeOTHER POLICIES37. Employer/SchoolName_____ Address_____28. Date of Birth (MM/DD/YYYY) //29. Marital StatusMarriedSingleOther30. SexMF38. Certificateholder/Employee StatusEmployedPart-time StatusFull-time StudentPart-time Student40. Employer/SchoolName_____ Address_____POCERTIFICATEHOLDER / EMPLOYEE39. I have been informed of the treatment and associated fees. I agree to be responsible for allcharges for Dental services and materials not paid by my Dental benefit plan, unless the treatingdentist or Dental practice has a contractual agreement with my plan prohibiting all or a portion of suchcharges.

3 To the extent permitted under applicable law, I authorize release of any information relatingto this (Patient/Guardian)Date (MM/DD/YYYY)41. I hereby authorize payment of the Dental benefits otherwise payable to me directly to thebelow named Dental (Employee/certificateholder)Date (MM/DD/YYYY)42. 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 currentseries:49. Place of City51. State52. Zip Code53. Radiographs or models enclosed?Yes, How many?_____ No54. Is treatment for orthodontics? YesNoIf service already commenced:55. If prosthesis (crown, bridge, dentures), is thisinitial placement?

4 YesNoIf no, reason for replacement:_____Date of prior placement:_____Date appliances placed_____Total mos. of treatmentremaining _____BILLING DENTIST56. Is treatment result of occupational illness or injury? No YesBrief description and dates_____57. Is treatment result of: auto accident? other accident? neitherBrief description and dates_____58. Diagnosis Code Index (optional)1. _____ 2. _____ 3. _____ 4. _____ 5. _____ 6. _____ 7. _____ 8. _____59. Examination and treatment plans List teeth in orderDate(MM/DD/YYYY)ToothSurfaceDiagnos is Index #Procedure CodeQtyDescriptionFeeAdmin. Use Only60. Identify all missing teeth with X PermanentPrimary Total Fee1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16A B C D EF G H I J Payment by other plan32 31 30 29 28 27 26 2524 23 22 21 20 19 18 17T S R Q PO N M L K Max.

5 Allowable Deductible61. Remarks for unusual services Carrier %Carrier paysPatient pays63. Address where treatment was performed62. 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)64. Zip CodeCONTINENTAL american Insurance COMPANY BOX 84075 COLUMBUS, GA 31993 Toll-Free: 1-866-849-0017 Fax: 1-866-849-2970 Patient Last Name InitialGROUP Dental PLAN Dear Certificateholder/Claimant: Enclosed is a Claim form for filing for Dental benefits.

6 Please have the Claim form completed as follows: FILING FOR Dental BENEFITS: complete the Patient section, boxes complete the Certificateholder/Employee section. Excluding boxes 31-38 and have your dentist complete the Billing Dentist section, Boxes 42- box time for a routine Claim is 10 business days. Failure to have this form properly completed may delay processing of your Claim . Please mail completed form to the address noted in boxes 3 through 7. You may fax your completed Claim to 1-866-849-2970. Should you have any questions, please do not hesitate to contact the Customer Service Center at 1-866-849-0017.