HEADER INFORMATION
1. Type of Transaction (Check applicable box)
Statement of Actual Services – OR – Request for Predetermination/Preauthorization
PRIMARY PAYER INFORMATION
3. Name, Address, City, State, Zip Code
PRIMARY SUBSCRIBER INFORMATION
4. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
5. Date of Birth (MM/DD/CCYY) 6. Gender 7. Subscriber Identifier (ID#)
M F U
8. Plan/Group Number 9. Employer Name
PATIENT INFORMATION
10. Relationship to Primary Subscriber (Check applicable box) 11. Student Status
Self Spouse Dependent Child Other FTS PTS
12. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY) 14. Gender
15. Patient ID/Account # (Assigned by Dentist)
M F U
RECORD OF SERVICES PROVIDED
24. Procedure Date 25. Area
(MM/DD/CCYY) of Oral
Cavity
26.
Tooth
System
27. Tooth Number(s) 28. Tooth
or Letter(s) Surface
29. Procedure
Code
29a. Diag. Pointer
30. Description 31. Fee
1
2
3
4
5
6
7
8
9
10
MISSING TEETH INFORMATION
33. (Place an ‘X’ on each missing tooth)
Permanent
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A
32 31 30 29 28 27 26 25 24 23
22 21 20 19 18 17 T
34a. Diagnosis Code(s)
34. Diagnosis Code List Qualifier
(ICD-9 = B, ICD-10 = AB)
(Primary diagnosis in “A”)
A _______________
CARRIER NAME AND ADDRESS:
2. Delta Dental of Illinois
P.O. Box 5402
Lisle, IL 60532
(Please do not use for DeltaCare dental HMO)
OTHER COVERAGE
16. Other Dental or Medical Coverage? No (Skip 17-23) Yes (Complete 16-23)
17. Subscriber Name (Last, First, Middle Initial, Suffix)
18. Date of Birth (MM/DD/CCYY)
21. Plan/Group Number
19. Gender 20. Subscriber Identifier (ID#)
M F U
22. Relationship to Primary Subscriber (Check applicable box)
Self Spouse Dependent Other
23. Other Carrier Name, Address, City, State, Zip Code
Primary
31a. Other
B C D E F G H I J
Fee(s)
S R Q P O N M L K
32. Total Fee
B ________________ C _______________ D ________________
35. Remarks
AUTHORIZATIONS
36. I have been informed of the treatment plan and associated fees. I agree to be responsible
for all charges for dental services and materials not paid by my dental benefit plan, unless pro-
hibited by law, or 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 by law, I consent to
your use and disclosure of my protected health information to carry out payment activities in
connection with this claim.
X
_________________________________________________________________________________________
Patient/Guardian signature Date
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me,
directly to the below named dentist or dental entity.
X
_________________________________________________________________________________________
Subscriber signature Date
BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not
submitting claim on behalf of the patient or insured/subscriber)
48. Name, Address, City, State, Zip Code
49. Corporate Entity NPI (Type 2) 50. License Number 51. TIN
52. Phone Number ( ) – 52a. Additional Provider ID
ANCILLARY CLAIM/TREATMENT INFORMATION
38. Place of Treatment (Check applicable box) 39. Number of Enclosures (00 to 99)
Radiograph(s) Oral Image(s) Model(s)
Provider’s Office Hospital ECF Other
40. Is Treatment for Orthodontics?
41. Date Appliance Placed (MM/DD/CCYY)
No (Skip 41-42) Yes (Complete 41-42)
42. Months of Treatment
43. Replacement of Prostheses?
44. Date Prior Placement (MM/DD/CCYY)
Remaining
No
Yes (Complete 44)
45. Treatment Resulting from (Check applicable box)
Occupational illness/injury Auto accident Other accident
46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
53. I hereby certify that the procedures as indicated by date are in progress (for procedures
that require multiple visits) or have been completed and that the fees submitted are the
actual fees I have charged and intend to collect for those procedures.
X
_________________________________________________________________________________________
Signed (Treating Dentist) Date
54. Individual NPI (Type 1) 55. License Number
56. Address, City, State, Zip Code 56a. Provider Specialty Code
57. Phone Number ( ) – 58. Treating Provider
Specialty
4521 (06/19)
Group Claim Form
