Fillable Dental Claim Filing Instructions & Claim Form (International Medical Group)

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Dental Claim Filing Instructions & Claim Form (International Medical Group)

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The Dental Claim Filing Instructions & Claim Form (International Medical Group) form is 6 pages long and contains:

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  • 6 check-boxes
  • 206 other fields

Country of origin: US
File type: PDF

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Dental Claim Form & Authorization
Page 1 of 6
WWW.IMGLOBAL.COM
DIRECTIONS FOR REQUESTING A PREDETERMINATION OF BENEFITS:
To save yourself from costly coinsurance and charges for expenses which are not covered, you should have your dentist submit a Predetermination of Benefits.
If charges for a course of dental treatment are expected to equal or exceed $500, have your dentist complete a pre-treatment claim form and send it to us along
with his treatment plan. We will review the treatment plan and tell you and your dentist how much will be paid by IMG and how much will be paid by the patient.
DIRECTIONS FOR SUBMITTING A CLAIM: (There are four parts to this form—A, B, C & D. Please carefully review the instructions below.)
Complete ALL PARTS of the Claim Form. If treatment was received in the United States you do not need to complete PART C.
Attach all original itemized bills, statements and invoices for services and supplies.
Please make certain that all documents indicate claimant’s name, date of service, diagnosis and the itemized charges.
Dental Claim Filing Instructions
& Claim Form
Please follow these instructions prior to filing a claim and when completing the Claim Form. Assistance is also available from the International
Medical Group® (IMG®) Customer Service Department at the telephone numbers listed above.
Notice: Any false statement, concealment or fraud shall render this insurance null and void and all claims hereunder shall be forfeited.
Our goal at IMG is to process your claim quickly, accurately and efficiently. In order to achieve this, the Claim
Form must be fully and accurately completed. Failure to do this will result in processing delays.
Please print legibly and complete ALL SECTIONS of this form. Mail, fax, or email completed form to:
Address: International Medical Group, Inc. Claims, P.O. Box 9162, Farmington Hills, MI 48333-9162 USA,
Call: +1.800.628.4664 or outside U.S. +1.317.655.4500; Fax: +1.317.655.4505
Email: customercare@imglobal.com
www.imglobal.com
Dental Claim Form & Authorization
Page 2 of 6
WWW.IMGLOBAL.COM
Dental Claim Form
& Authorization
PART A. To be completed by the claimant for all claims
Claimant/Patient Name:
(As it appears on ID card)
Group Name:
Male Female
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Claimant’s Relationship to Primary Insured: Self Spouse Child Other
Name of Primary Insured:
(As it appears on ID card)
Insured ID #:
Male Female
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Home Country Address:
Current Address: City:
State: Postal Code: Home Phone: Work Phone:
Communications should be sent via email to:
Are you a full-time student?
Yes No
If yes, please provide the following information:
Name of School:
Street Address: Phone:
City: State: Postal Code: Country:
Email:
How many months of the year are you residing in the U.S.?
If claimant is or may be covered by other coverage, complete the items below.
Name of Primary Insured: (as it appears on ID card) Date of Birth: ___/___/___ (MM/ DD/YYYY)
Insured mailing address: City: State: Postal Code:
Name of other carrier: ID # for other coverage:
Type of other coverage: Carrier Phone number:
Carrier address: City: State: Postal Code:
Name of employer: Employer Phone number:
Employer address: City: State: Postal Code:
Please print legibly and complete ALL SECTIONS of this form. Mail, fax, or email completed form to:
Address: International Medical Group, Inc. Claims, P.O. Box 9162, Farmington Hills, MI 48333-9162 USA,
Call: +1.800.628.4664 or outside U.S. +1.317.655.4500; Fax: +1.317.655.4505
Email: customercare@imglobal.com
www.imglobal.com
Dental Claim Form & Authorization
Page 3 of 6
WWW.IMGLOBAL.COM
PART B. (If you need additional space, please attach a separate sheet.)
1. Is this condition the result of an accident? Yes No
If yes,
A. Provide details of the accident such as,
What were you doing when you were injured?
Explain your injuries
B. Is this condition related to employment? Yes No
If yes, are you applying for Worker’s Compensation benefits?
Yes No
C. Did this accident or injury involve a motor vehicle? Yes No
If yes, please list the names of involved parties, insurance carriers, and policy numbers
D. Was a police report filed? Yes No
If yes, please identify the Police Department where it was filed.
2. Had these teeth previously been repaired? Yes No
If yes, please list which ones, what was done, and date repaired.
___/___/___ (MM/ DD/YYYY)
3. Are there any claims attached for orthodontics (braces)? Yes No
If yes, please provide the initial placement date.
___/___/___ (MM/ DD/YYYY)
4. Are any of these services for teeth that have been previously extracted? Yes No
If yes, please provide the date of extraction and what tooth (teeth) were extracted.
Dental Claim Form & Authorization
Page 4 of 6
WWW.IMGLOBAL.COM
PART C. Complete for all treatment received outside of the United States.
Date of service
(MM/ DD/YYYY)
Provider
What type of
service and/or
name of drug
provided?
What was the
illness/injury?
City/
country
Type of
currency
paid or billed
Total charge
paid or billed
Converted to
U.S. funds
Office use only
ALTERNATE PAYEE INFORMATION
Name:
Street Address: Phone:
City: State: Postal Code: Country:
Email:
Dental Claim Form & Authorization
Page 5 of 6
WWW.IMGLOBAL.COM
Account Holder’s Name:
Bank Name:
Bank Address: City: Country:
Currency of reimbursement: Bank 9 digit ABA number—U.S. banks:
Bank 8 or 11 digit SWIFT code—non-U.S. banks: Sort code:
Bank account number: Bank IBAN:
Intermediary Bank Details (if applicable):
Name of intermediary bank:
Intermediary bank SWIFT code: Intermediary bank account number:
PART D. PAYMENT DETAILS (Checks will only be issued to a United States address.)
Make payment to the provider
Make payment to primary insured
Reimbursement method
Bank ACH or wire transfer (complete below) Check
Make payment to alternate payee
Reimbursement method
Bank ACH or wire transfer (complete below) Check
PART E. AUTHORIZATION—to be completed by the claimant for all claims.
I verify that all information contained in this form is true, correct and complete to the best of my knowledge.
I authorize any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company,
group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or
mental condition, or the financial or employment status of the insured named below, to provide this information to International Medical Group, Inc. or any
agent or administrator acting on its behalf.
I understand that I have the right to receive a copy of this authorization upon request. A copy of this shall be as valid as the original.
This authorization is valid for twelve months from the date signed.
Print Name of Insured: ________________________________________________________________________
ID #:
Signature of Insured/Guardian:
X_________________________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
AUTHORIZATION:
I authorize payment of any benefits for eligible medical expenses to the provider or other supplier of services which is entitled to payment of the attached bills.
Signature of Insured/Guardian: X_________________________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
If needed you can overnight packages to following address:
2960 North Meridian Street, Indianapolis, IN 46208
Dental Claim Form & Authorization
Page 6 of 6
WWW.IMGLOBAL.COM
Version 0719IN01200795A190731
PART F. Privacy and Confidentiality Release Form
By completing this form, you are providing your consent to IMG to discuss your claim activity with the person(s) listed below. Without this release
form, IMG cannot discuss your claims activity with anyone other than your physician(s) or provider(s) of service.
I authorize IMG to discuss my claim with ____________________________________ who is ___________________________________________
This authorization is valid for __________ months from the date signed (maximum of 12 months).
I give IMG permission to release
the following information:
(Please select and initial)
________________ Financial and claim information related to medical bills or claim form.
________________ Provider name, date of service, total charge, total amount paid, and date of payment.
________________ Insurance ID number and/or social security number.
Under no circumstances can IMG release medical information obtained from your physician or provider of service to you or anyone. Your medical information
has been disclosed to us from your physician or provider of service and we are prohibited by federal law for further disclosure. Please contact your physician
or provider of service for your medical information.
Print Patient Name: ____________________________________________________________ Insurance ID #:
Signature of the Patient or parent if the patient is a minor child: X________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
PLEASE PROVIDE YOUR CURRENT MAILING ADDRESS:
Street Address:
City: State: City: Country:
Postal Code:
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Dental Claim Filing Instructions & Claim Form (International Medical Group)

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Completed 14 June 2021

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