2. Date of Birth (MMDDCCYY) 3. Gender 4. Policyholder / Subscriber ID (SSN or ID#)
M
F
5. Plan or Group
6. Employer
Number
Name
PATIENT INFORMATION
7. Relationship to Policyholder/Subscriber in #1 Above
Self Spouse Dependent Child Other
8. Patient Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code
9. Date of Birth (MMDDCCYY) 10. Gender 11. Patient ID/Account # (Assigned by Dentist)
M F
12. Remarks
SUBSCRIBER INFORMATION
1. Policyholder / Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code
TRANSACTION AND PREDETERMINATION INFORMATION
13. Type of Transaction (Mark all Applicable Boxes)
Statement of Actual Services Request for Predetermination/Pre-treatment Estimate
EPSDT/ Title XIX
Encounter
14. Predetermination/
Pre-treatment
Estimate Number
TREATMENT INFORMATION
15. Treatment Resulting From
Occupational Illness/injury Auto accident Other accident
16. Date of Accident (MMDDCCYY) 17. Auto Accident State
18. Place of Treatment 19. Number of Enclosures (00 to 99)
Radiograph(s) Oral Image(s) Model(s)
Provider's Office Hospital ECF Other
20. Is Treatment for Orthodontics? 21. Date Appliance Placed (MMDDCCYY)
No (Skip 21-22) Yes (Complete 21-22)
22. Months of
23. Replacement of Prosthesis? 24. Date of Prior Placement (MMDDCCYY)
Treatment
Remaining
No Yes (Complete 44)
OTHER INSURANCE COVERAGE
25. Other Coverage?
Dental (Complete 26-32) Medical (Complete 26-32)
None
26. Name of Other Coverage Policyholder / Subscriber (Last, First, Middle Initial, Suffix)
27. Date of Birth (MMDDCCYY) 28. Gender 29. Policyholder / Subscriber ID (SSN or ID#)
M F
31. Patient's Relationship to Person Named in #26
30. Plan or
Group
Self Spouse Dependent Other
Number
32. Other Insurance Company / Dental Benefit Plan Name, Address, City, State, ZIP Code
D.
33. Diagnosis Codes
A. B. C.
RECORD OF SERVICES PROVIDED
34. Procedure Date
35. Area of
(MMDDCCYY)
Oral Cavity
1
2
3
4
5
6
7
8
MISSING TEETH INFORMATION
44. (Place an 'X' on each missing tooth)
40. Diagnosis
37. Tooth
38. Quantity 39. Procedure
36. Tooth Number(s)
Pointer
Surface
Code
or Letter(s)
(A, B, etc.)
Primary
43. Total
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I J
Fee
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T S R Q P O N M L K
Permanent
41. Description 42. Fee
AUTHORIZATION - RELEASE OF INFORMATION
45. 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 prohibited 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.
Patient/Guardian signature Date
BILLING DENTIST OR DENTAL ENTITY
47. Dentist or Entity Name, Address, City, State, ZIP Code
48. NPI
50. SSN
49. License
or
Number
TIN
51. Phone 52. Additional
Provider ID
Number
AUTHORIZATION - ASSIGNMENT OF BENEFITS
46. 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
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
X
Signed (Treating Dentist)
54. Treatment Location Address, City, State, ZIP
Date
Code - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
55. NPI
57. Provider
56. License
Specialty
Number
Code
59. Additional
58. Phone
Number
Provider ID
Delta Dental Enterprise Claim Form
Version 1, Rev 0 10/12/2011
X
Delta Dental of Pennsylvania
PO Box 2105
Mechanicsburg, PA 17055-2105
717-766-8500 800-932-0783
TTY/TDD 888-373-3582
0.00
click to sign
signature
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signature
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signature
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Claim Form Disclosure
You may be subject to civil and criminal penalties for knowingly providing false or misleading information.
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
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 this title. 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.
Arkansas: Any person who knowingly presents a false or
fraudulent claim for payment for 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. California: For your protection, California law requires the following to appear on this form: Any person
who knowingly presents 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: 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. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the
insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud or deceive any
insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime
punishable by fines or imprisonment, or both. Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a
statement containing any false, incomplete, or misleading information is guilty of a felony. Indiana: Any person who knowingly, and with intent to
defraud an insurer, files a statement of claim containing false, incomplete or misleading information commits a felony. Kansas: Any person who
knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act
punishable under law and may be subject to civil penalties. 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 any fact
material thereto commits a fraudulent insurance act, which is a crime. Louisiana: 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. Maine: 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 and willfully presents a false or fraudulent claim for payment for a loss or benefit or who knowingly and willfully presents false information in
an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota: A person who files a claim with
intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud
or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and
punishment for insurance fraud as provided in R.S.A. 638.20. New Jersey: Any person who knowingly files a statement of claim containing any false
or misleading information is subject to civil and criminal penalties. New Mexico: 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 civil fines
and criminal 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 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. Ohio: Any person who, with the intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. 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. Pennsylvania: 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 subjects such
person to criminal and civil penalties. Puerto Rico: Any person who knowingly and with the intention to defraud presents false information in an
insurance application or, who presents helps or has a fraudulent claim presented for the payment of a loss or other benefit, or presents more than one
claim for the same loss or damage, will incur in a felony and if convicted, will be sanctioned for each violation with a fine of no less than five thousand
($5,000) dollars or no more than ten thousand ($10,000) dollars or imprisonment by the fixed term of three years, or both punishments. With
aggravating circumstances the fixed term of the punishment could go up to five (5) years; with mitigating circumstances the punishment could be
reduced to a minimum of two (2) years. Rhode Island: 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.
Tennessee: 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. Utah: Any person who knowingly presents false or fraudulent
underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or
fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state
prison. Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding
the company. Penalties include imprisonment, fines and denial of insurance benefits. Washington: It is a crime to knowingly provide false,
incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and
denial of insurance benefits. 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.
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