Fillable Dental expense claim SECTION 1: To be completed

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Dental expense claim SECTION 1: To be completed

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Group Dental
JY0333 (05/18)
Page 1 of 5
Fs/f
Dental expense claim
Metropolitan Life Insurance Company
SECTION 1: To be completed by Employee
Patient information
1. First name Middle name Last name
2. Relationship to employee
Self Spouse Child Other
3. Sex
Male
Female
4. Married?
Yes No
5. Patient DOB 6. For office use
If full-time student (age 19 or over)
7. School name and address
City State ZIP
8. ID number 9. If disabled (age 19 or over)
Yes No
10. Name of group Dental program
Employee information
11. First name Middle name Last name
12. Residence mailing address City State ZIP
13. Employee DOB
14. Office phone (area code)
15. Are other family members employed?
Yes No
16. Name of Employed family member
Social Security/ID number Date of birth
17. Name of employer for Item 16
18. Employer address
City State ZIP
Yes
No
(If yes, complete
the following:)
19. Is patient covered by
another Dental Plan?
Dental plan name Group number
Name of Carrier
Address of Carrier
City State ZIP
20. I authorize release of any information relating to this claim.
Signature of patient or authorized representative if minor
If authorized representative,
relationship to minor Date
21. I certify that the above information is correct.
Employee signature
Date
22. I authorize payment directly to the below-named dentist.
Employee signature Date
Page 2 of 5
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JY0333 (05/18)
SECTION 2: To be completed by Dentist
23. Dentist − First name Middle name Last name
24. Mailing address City State ZIP
25. Phone number 26.
License number
27.
Dentist SSN or T.I.N.
28.
Provider specialty code
29.
NPI (treating dentist)
30.
NPI (billing entity, if different)
31.
First visit date current series
32.
Place of treatment
Office Hospital ECF Other
33. Radiographs or Models enclosed?
Yes No
How many?
34.
Is treatment result of occupational illness or injury?
(If yes, enter brief description and dates)
Yes No
35.
Is treatment result of auto accident?
(If yes, enter brief description and dates)
Yes
No
36.
Other accident?
(If yes, enter brief description and dates)
Yes No
37. Are any services covered by another plan?
(If yes, enter brief description and dates)
Yes No
38.
If prosthesis, is this initial placement? (If no, reason for replacement)
Yes No
39. Date of prior replacement
40. Is treatment for
orthodontics?
Yes
No
If services already commenced, date appliance placed
Months of treatment remaining
Dentist’s −
Pretreatment estimate
Statement of actual services (Be sure to sign below)*
41. Examination and Treatment Plan – List in order from tooth #1 through tooth #32 (Use charting system
shown)
Tooth #
or Letter
Surface
Description of Services
(Including X-Rays, Prophylaxis,
Materials Used, Etc.)
Date Service
Performed
(mm/dd/yyyy)
ADA
Procedure
Number
Fee
For
Carrier
Use Only
Total fee
Actually charged
42. I hereby certify that the services listed above
will be have been performed.
*Signature of Dentist
Date signed
43. Address where treatment was performed - Street City State ZIP
Page 3 of 5
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JY0333 (05/18)
SECTION 3: Instructions (Please review these instructions before submitting claim.)
1. FRAUD WARNINGS
Before completing this form, please read the following fraud warning for the state where you reside and for the state
where the insurance policy under which you are claiming a benefit was issued.
Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, Minnesota, New Mexico, Ohio, Rhode
Island, and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject
to fines and confinement in prison.
Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim
containing false, incomplete or misleading information may be prosecuted under state law.
Arizona: For your protection, Arizona law requires the following statement to appear on this
form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
California: For your protection, California law requires the following to appear on this form: Any person who
knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
fines and confinement in state prison.
Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,
fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose
of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
Delaware, Idaho, Indiana, and Oklahoma: WARNING: 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.
Florida: A person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree.
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files 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.
Maine, Tennessee, Virginia, and Washington: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purposes of defrauding the company. Penalties may include
imprisonment, fines or a denial of insurance benefits.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit
or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a
statement of claim containing false, incomplete or misleading information is subject to prosecution and punishment for
insurance fraud as provided in RSA 638:20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is
subject to criminal and civil penalties.
New York: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation.
Oregon and Vermont: Any person who knowingly presents a false statement of claim for insurance may be guilty of
a criminal offense and subject to penalties under state law.
Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application
for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or
files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for
each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000);
or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be
increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to
a minimum of two (2) years.
Page 4 of 5
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JY0333 (05/18)
Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime
and may be subject to fines and confinement in state prison.
Pennsylvania and all other states: 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.
2. CLAIM SUBMISSION INFORMATION
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 (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 operations, 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 in 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 $300 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 $300.)
6. If total charges for the planned course of treatment will be less than $300, the claim form should be
completed when treatment is completed and mailed or faxed to the address or fax number 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 $300 or more, check the box noted
“Pretreatment estimate” and complete items 23 through 42. The completed claim form should be sent to the
address shown below 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.
3. If the address where treatment was performed is different from the mailing address in item 24, complete item 43.
4. 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 pretreatment estimate.
5. If authorized by the employee, benefit payments will be made directly to you.
Page 5 of 5
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JY0333 (05/18)
SECTION 4: How to submit this form
• If you are submitting a claim, please complete and detach the first and second pages only and mail them to
the below address or fax them to the number indicated.
• If you are requesting that the form be translated into Spanish or Chinese, please visit our website,
www.metlife.com, and download the applicable claim form from our Dental Insurance Center.
• Or you may mail the entire six (6) pages of this form to the address shown on page 6.
Mail:
MetLife Dental Claims
P.O. Box 981282
El Paso, TX 79998-1282
Fax:
1-859-389-6505
Dentist's telephone:
1-877-638-3379
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Completed 27 May 2021

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