Any updates to these instructions will be posted on the ada’s web site (ada.org). Date of birth (mm/dd/ccyy) 22.
Self spouse dependent child other 19.
Self insured dental services claim form. Charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or. You must sign the claim form in item 21. Insured's address and telephone number 4.
It is important that you discuss your treatment plan and charges with your dentist prior to starting any work. Self insured dental services po box 9005, dept. Dental services and materials not paid by my dental benefit plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges.
Total of all fees listed on the claim form. Be aware that the fund does not recommend or endorse any dentists. Any updates to these instructions will be posted on the ada’s web site (ada.org).
We cannot accept or process faxed bills. Claims must be submitted within 3 months of being incurred to be eligible for reimbursement 1. Report missing teeth on each claim submission.
Comprehensive ada dental claim form completion instructions are printed in the cdt manual. You can arrange for metlife to make payment directly to the dentist by completing item 22. Comprehensive ada dental claim form completion instructions are printed in the cdt manual.
Insured's name (surname, first name, middle initial) date of birth 2. Actual payment may differ from the estimate. Please do not fax bills to the above number.
We would like to show you a description here but the site won’t allow us. Comprehensive ada dental claim form completion instructions are printed in the cdt manual. Completing either of these forms creates a priority work item for the claim manager to review.
Www.asonet.com dental claims must be filed within 12 months after the date of service. Used when other fees applicable to dental services provided must be recorded. You should exercise the same care and apply the same criteria in selecting a participating dentist that you would.
• if you are covered by other dental coverage, attach a copy of the bills Patient’ s relationship to other insured (check applicable box) self spouse dependent other primary insured information 12. Signed (patient, or parent if minor) 12.
Date of birth (mm/dd/ccyy) 22. Fax the completed form to: Dental care claim form note:
If you wish benefits to be paid directly to yourself. Gender m f u 23. Or may choose any dentist and submit for reimbursement according to the uft welfare fund schedule of covered dental expenses.
Self spouse dependent child other 19. Reserved for future use address, city, state, zip code 21. Reserved for future use 21.
Gender m f u 23. Such fees include state taxes, where applicable, and other fees imposed by regulatory bodies. Cx076 www.asonet.com claim forms are available from:
Company/plan dentist or supplier patient/insured information d m y 3. To the extent permitted under applicable law, i authorize release of any information relating to this claim. Type of transaction (check all applicable boxes) epsdt/title xix.