1. PATIENT NAME 2. RELATIONSHIP TO EMPLOYEE
3. SEX 4. PATIENT BIRTHDATE 5. IF FULL TIME STUDENT AND OVER AGE 18, INDICATE:
SELF
SPOUSE CHILD
OTHER M F DAY YEARMO.
SCHOOL CITY
6. EMPLOYEE/
SUBSCRIBER
NAME
FIRST MIDDLE LAST
EMPLOYEE MAILING
ADDRESS
CITY, STATE, ZIP
ZIP CODE
PHONE NO.APT. NO.
7. EMPLOYEE
SOCIAL SECURITY NUMBER
8. EMPLOYEE BIRTHDATE
DAY YEARMO.
9. EMPLOYER (COMPANY) NAME AND ADDRESS/
UNION LOCAL
10. GROUP NUMBER
11. IS PATIENT COVERED BY ANOTHER PLAN OF BENEFITS?
IF YES, COMPLETE ITEMS 12 THROUGH 15.
12a. NAME AND ADDRESS OF DENTAL CARRIER(S), ITEM 11.
12b. GROUP NUMBER 13. NAME AND ADDRESS OF EMPLOYER, ITEM 11
14a. EMPLOYEE NAME, ITEM 11
(IF DIFFERENT FROM PATIENT’S)
14b. EMPLOYEE
SOCIAL SECURITY NUMBER
14c. EMPLOYEE BIRTHDATE
MO.
DAY YEAR
15. RELATIONSHIP TO PATIENT
SELF SPOUSE PARENT
OTHER
16. DENTIST NAME
17. MAILING ADDRESS
CITY, STATE, ZIP
LICENSE NUMBER
PHONE NO.
ZIP CODE
24. IS TREATMENT RESULT
OF OCCUPATIONAL
ILLNESS OR INJURY?
25. IS TREATMENT RESULT
OF AUTO ACCIDENT?
27. ARE ANY SERVICES
COVERED BY A NON-
DENTAL PLAN?
28. IF PROSTHESIS, IS THIS
INITIAL PLACEMENT?
IF NO, ENTER REASON
FOR REPLACEMENT.
30. IS TREATMENT FOR
ORTHODONTICS?
26. OTHER ACCIDENT?
NO YES
NO YES
29. DATE OF PRIOR
PLACEMENT
MOS. TREATMENT
REMAINING
DATE APPLIANCES PLACED
IF SERVICES
ALREADY
COMMENCED
ENTER
IF YES, ENTER DATES, BRIEF DESCRIPTION AND ANY AMOUNT PAID.
18. DENTIST SOC. SEC. NO. OR T.I.N. 19. DENTIST LICENSE NO. 20. DENTIST PHONE NO.
21. FIRST VISIT DATE
CURRENT SERIES
22. PLACE OF TREATMENT
OFFICE HOSP. ECF OTHER
23. RADIOGRAPHS OR
MODELS ENCLOSED?
NO YES
HOW
MANY?
1. PLEASE TYPE OR PRINT
2. DO NOT USE A HIGHLIGHTER
3. STAPLE X-RAYS TO TOP RIGHT CORNER
4. SEND PAGE 1 TO DELTA
DELTA DENTAL OF CALIFORNIA ENCOURAGES DENTAL OFFICES TO SUBMIT CLAIMS ELECTRONICALLY.
DELTA USE ONLY
P.O. Box 997330
Sacramento, CA 95899-7330
Customer Service (888) 335-8227
31. EXAMINATION AND TREATMENT RECORD - LIST IN ORDER FROM TOOTH NO. 1 THROUGH TOOTH NO. 32, USE CHARTING SYSTEM SHOWN.
TOOTH
NO. OR
LETTER
SUR-
FACES
DATE SERVICE
COMPLETED
PROCEDURE
NUMBER
FEE
DESCRIPTION OF SERVICE
(INCLUDING X-RAYS, PROPHYLAXIS,
MATERIALS USED, ETC.)
MD Y
PLEASE MAKE SURE EMPLOYEE’S MAILING ADDRESS IS LEGIBLE, CURRENT & COMPLETE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
MY DENTIST MAY GIVE DELTA AND ANY OTHER CARRIER NAMED
ABOVE INFORMATION ABOUT MY DENTAL CONDITION OR
TREATMENT NEEDED TO DETERMINE BENEFITS FOR UP TO 5 YEARS
FROM THIS DATE.
SIGNATURE OF PATIENT
(OR PARENT OR GUARDIAN)
DATE
You may receive a copy of this authorization on request.
PREDETERMINATION OF COST
THE TREATMENT LISTED IS NECESSARY IN MY PROFESSIONAL JUDGMENT
AND I REQUEST A PREDETERMINATION OF COST.
DENTIST
SIGNATURE
DATE
TREATMENT COMPLETED - PAYMENT REQUESTED
THE TREATMENT LISTED WAS COMPLETED. I WILL CHARGE AND INTEND TO COLLECT THE
ENTIRE PORTION OF THE FEES STATED ABOVE WHICH DELTA DETERMINES TO BE THE
PATIENT’S RESPONSIBILITY, AND I WILL NOT WAIVE, REDUCE OR REBATE ANY OF THAT
PORTION UNLESS I EXPRESSLY SO STATE ON THIS FORM.
DENTIST
SIGNATURE
DATE
TOTAL FEE
CHARGED
PATIENT
PAYS
PLAN
PAYS
AMOUNT APPLIED
TO DEDUCTIBLE
SEE DENTIST’S HANDBOOK FOR PARTICIPATION RULES.
ATTENDING DENTIST’S STATEMENT
DELTA 105 Rev. 7/03
1. SUBMIT PAGE 1 TO DELTA.
2. RETAIN PAGE 2 FOR YOUR FILES.
32. REMARKS FOR UNUSUAL SERVICES OR
®
YES NO
IDENTIFY MISSING TEETH WITH "X"
FACIAL
9
10
11
12
13
14
15
16
J
I
H
G
F
E
D
C
B
A
1
2
3
4
5
6
7
8
17
18
19
20
21
22
23
2425
26
27
28
29
30
31
32
T
S
R
Q
P
O
N
M
L
K
LINGUAL
FACIAL
LINGUAL
LEFT
AMOUNT PAID BY OTHER COVERAGE
Delta Dental of California
PRIMARY
PERMANENT
LOWER UPPER
RIGHT
LOWER UPPERLOWER UPPER
LOWER UPPER
RIGHT
