1.
P
A
T
I
E
N
T
C
O
V
E
R
A
G
E
2. 3. Carrier name and Address
Dentist's pre-treatment estimate Medicaid Claim
UMR
PO Box 30541
Salt Lake City, UT 84130-05
41
1-800-826-9781
Dentist's statement of actual services EPSDT
Prior Authorization No.
Provider ID No.
Patient ID No.
4. Patient name 5. Relation to insured 6. Sex 7. Patient birthdate 8. If full time student
first m.i. last
m f MM DD YYYY school
city
self child
spouse other
9. Employee/subscriber name
and mailing address
10. Employee/subscriber
soc sec number
11. Employee/subscriber
bir
thdate
12. Employer (company)
name and address
13. Group number
MM DD YYYY
14. Is patient covered by another dental plan?
15-A. Name and address of carrier(s) 15-B. Group No.(s) 16. Name and address of employer
Yes No
If yes, complete 15-A.
Is patient covered by a medical plan? Yes No
17-A. Employee/subscriber name
(if
different than patient's)
17-B. Employee/subscriber
soc. sec. number
11. Employee/subscriber birthdate 18. Relationship to insured
MM DD YYYY
self
child
spouse other
19. I have reviewed the following treatment plan and fees. I agree to be responsible for all charges for
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. To the
extent permitted under applicable law, I authorize release of any information relating to this claim.
Signed (Patient, or parent if minor)
20. I hereby authroize payment of the dental benefits otherwise payable to me directly to the
below
named dental entity
Signed (Employee/subscriber)
B
I
L
L
I
N
G
D
E
N
T
I
S
T
21. Name of Billing Dentist or Dental Entity
22. Address of where payment should be remitted
23. City, State, Zip
24. Dentist Soc Sec or T.I.N. 25. Dentist license No. 26. Dentist phone No.
27. First visit date
current series
28. Place of treatment 29. Radiographs No Yes How
Many? Offic
e Hosp ECF Other
30. Is treatment result
of occupational
illness or injury?
31. Auto accident?
32. Other accident?
33. If prosthesis, is this
in
itial placement?
35. Is treatment for
orthodontics?
No Yes If yes, enter brief descript
ion and dates
(If no, reason for replacement) 34. Date of prior
placement
If
services already
commenced, enter:
Date appliances
placed
Mos. treatment
remaining
36. Identify missing teeth with "X"
37. Examination and treatment plan - List in order from tooth No. 1 through tooth No. 32 - Use charting system shown.
Tooth
No. o
r
letter
Surface
38. Remarks for u
nusual services
Description of Service
(includi
ng x-rays, prophylaxis, materials, etc.)
Line No.
Date Service
Pe
rformed
Procedure
Number
MM
DD YYYY
41. Total Fee
Charged
42. Payment by
other p
lan
39. I hereby certify t
hat the procedures as indicated by date have been completed and that the fees submitted
are the actual fees I have charged and intend to collect for those procedures.
( Treating Dentist ) License Number Date
40. Address where treatment was performed
City State Zip
CF0040 09-18 Page 1 See next page
For
administrative
use only
Fee
Max allowable
Deductible
Carrier %
Carrier pays
Patient pays
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