To Be Completed by Employee (You must review the important statements on page 2 before completing this section of the form)
Metropolitan Life Insurance Company
1. Patient First Name Middle Last 2. Relationship to Employee
Self Spouse Child
Other
3. Sex
Male
Female
4. Married?
Yes
No
5. Patient Date of Birth
Mo. / Day / Year
6. For Office Use
8. EMPLOYEE Social Security / ID Number 9. If Disabled
(Age 19 or Over)
Yes No
10. Name of Group Dental Program7. If Full Time Student (Age 19 or Over)
School City State
11. Employee First Name Middle Last 12. Employee Date of Birth
13. Office Phone (Area Code)
14. Employee Residence Mailing Address 15. City, State, Zip
16. Are other Family Members Employed?
Yes
No
Name Social Security / ID Number
18. Name and Address of Employer for Item 1617. Date of Birth
19. Is Patient Covered by Another Dental Plan?
Yes No (If Yes, complete the following:)
Dental Plan Name Group No. Name and Address of Carrier
20. I Authorize Release of any Information Relating to this Claim
_______________________________________ _______________
(Signature of Patient or Signature of Authorized
Representative if Minor)
If Authorized Representative, Relationship to Minor
To Be Completed by Dentist
22. I Authorize Payment Directly to the Below Named Dentist.
__________________________________ __________________
Employee Signature Date
21. I Certify that the Above Information is Correct.
____________________________________ __________________
Employee Signature Date
23. Dentist Name 24. Mailing Address City State Zip
25. Dentist Social Security Number or T.I.N.
29. Place of Treatment
Office Hospital ECF Other _______________________________________
26. Dentist License Number
27. Dentist Phone Number
28. First Visit Date Current Series 30. Radiographs or Models Enclosed?
Yes No How Many?_____________
31. Is Treatment Result of Occupational Illness or Injury?
Yes
No
(If Yes, Enter Brief Description and Dates)
32. Is Treatment Result of Auto Accident?
Yes
No
(If Yes, Enter Brief Description and Dates)
33. Other Accident?
Yes
No
(If Yes, Enter Brief Description and Dates)
35. If Prosthesis, is this Initial Placement?
Yes
No
(If No, Reason for Replacement)
34. Are any Services Covered by Another Plan?
Yes
No
(If Yes, Enter Brief Description and Dates)
36. Date of Prior Replacement?
37. Is Treatment for Orthodontics?
Yes No
If Services Already Commenced, Enter Date Appliance Placed Months of Treatment Remaining
Dentist’s Pretreatment Estimate Statement of Actual Services (Be sure to sign below)*
38. Examination and Treatment Plan – List in Order From Tooth #1 through Tooth #32 (Use Charting System Shown)
Tooth #
or
Letter
Description of Services
(Including X-Rays, Prophylaxis, Materials Used, Etc.)
Date Service
Performed
Mo. / Day / Year
ADA
Procedure
Number
FeeSurface
For Carrier
Use Only
39. I Hereby Certify That The Services Listed Above
Will Be
Have Been Performed
* Signature of Dentist ____________________________________________________ Date ___________________
Total Fee
Actually Charged
40. Address where treatment was performed
Street _______________________________________________________________
City ___________________________State ______________Zip ________________
SBC Dental
Page 1 of 2
Dental Expense Claim
Date
Small Business Center
Please Review Before Submitting Claim
Information for Employee
1. Complete your section of the claim form (items 1 through 21) in full to assure positive identification and prompt payment. Please print or type.
Note: Item 8 (Employee Social Security Number / ID Number) must be completed for the claim to be processed.
2. Patient Consent. By signing item 20 the patient (or parent or other authorized representative) consents to the use and disclosure of information relating to the
services provided by the dentist or health care professional for the purpose of treatment, payment or health care operation, including submission of a claim for dental
benefits to a provider or administrator of dental benefit plans. This consent will be valid for as long as the patient is entitled to coverage under a dental plan. You are
entitled to a copy of this consent. This consent may be revoked in writing delivered to your dentist or health care professional, but such revocation will not affect any
action taken in reliance on this consent prior to revocation. Upon receipt of revocation or refusal to sign a consent, your dentist or health care professional may decline
to provide or continue treatment. If this consent is signed by the authorized representative of the patient, the relationship of the authorized representative must be
provided in item 20.
3. You must sign the claim form item 21.
4. You can arrange for MetLife to make payment directly to the dentist by completing item 22. If you wish benefits to be paid directly to yourself, do not complete item
22. In either case, a statement of benefits paid will be sent to you.
5. If total charges for the planned course of treatment are expected to be $200 or more, the form should be completed and submitted to MetLife prior to the
commencement of the course of treatment for a pretreatment estimate of benefits. MetLife will notify you of your benefits payable.
(If you wish, a pretreatment estimate may be requested for anticipated dental expenses of less than $200.)
6. If total charges for the planned course of treatment will be less than $200, the claim form should be completed when treatment is completed and mailed to the address
shown below.
Dental Coverage is subject to specific limitations and exclusions. Please refer to your booklet for a description of covered services, schedule of
benefits payable, limitations and exclusions.
Information for Attending Dentist
1. Benefits are payable in accordance with four Classes of Services. It is therefore important that a separate fee is indicated for each item of service performed.
2. If total charges for a course of treatment are expected to be $200 or more, check the box noted “Pre-treatment estimate” and complete items 23 through 39. The
completed claim form should be sent to the address shown below.
3. If total charges for a course of treatment are expected to be $200 or more, check the box noted “Pre-treatment estimate” and complete items 23 through 39. The
completed claim form should be sent to MetLife prior to the commencement of the course of treatment. MetLife will review the claim (and any supplementary
information required) and notify your patient of the benefits payable.
A pre-treatment estimate of benefits is not intended to preclude a course of treatment agreed upon by you and your patient. The intent is to avoid any misunderstanding
concerning the benefits payable under the dental plan. A pre-treatment estimate is not necessary for oral examinations, cleanings, fluoride applications, dental x-rays,
or emergency treatment.
4. If the address where treatment was performed is different than the mailing address in item 24, complete item 40.
5. Generally, we do not request x-rays where standard filling materials are used. Pre-operative x-rays are requested only in connection with prosthetics, fixed bridgework,
or cast restorations. Occasionally we may request x-rays that relate to
other dental services.
In an effort to reduce your costs and inconvenience, we request your
cooperation in submitting x-rays only in the above mentioned
circumstances or when specifically requested. This will also enable
us to expedite the processing of a pre-treatment estimate.
6. If authorized by the employee, benefit payments will be made directly
to you.
Mail Completed form to:
MetLife Dental Claims P.O. Box 981282 El Paso, TX 79998-1282
Claim: 800-ASK-4MET
275 4638
If you are covered under a self-insured plan or insured under a policy issued in any state other than those listed below, or if
you reside in any state other than those listed below, then the following warning may apply to you:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
If you are insured under a policy issued in one of the following states, or if you reside in one of the following states, one of
the following state warnings may apply to you:
New Y
ork (only applies to Accident and Health Benefits (AD&D/Disability/Dental): I know it is a crime to fill out
this form with facts I know are false or to leave out facts I know are important. I know that if I do this, I may also have to
pay a civil penalty of up to $5,000 plus the value of the claim.
Florida:
Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or a statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, and may subject such
person to criminal and civil penalties.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject
to criminal and civil penalties.
Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Kansas and Oregon: Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or a statement of claim containing any materially false information or conceals, for the purpose
of misleading, information concerning any fact material thereto may be guilty of insurance fraud, and may be subject to
criminal and civil penalties.
V
irginia:
Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, files a
claim containing a false or deceptive statement may have violated state law.
Employee Signature _____________________________________________ Date __________________________________
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