Yes No

TOOTH DATE TOOTH DATE

Signature of Subscriber or Spouse Date

No Yes

Signature of Subscriber or Spouse Date

No Yes

If yes, what was the orginal prosthesis? Mo. Day Year Tooth Number(s)

Original Damaged Lost or stolen Other: (explain)

SPI

RPL

No Yes

Date appliance was placed: Expected completion date of orthodontic treatment:

Total charge for active treatment

ESTIMATE OF ELIGIBLE BENEFITS

WORK COMPLETED - PAYMENT REQUESTED

Dentist’s Signature Phone #

Mo. Day Year

Female Male

EE SP CH Self Spouse Child

Other Explain:

CHECK IF NEW ADDRESS City State Zip Code

Email Address

No Yes

If yes, name of other insurance:

Name of Policy Holder

No Yes

No Yes

No Yes

Other Policy ID Number Mo. Day Year

No Yes

No Yes If yes, name of referring provider

Address

POI

SOPL

OFFICE USE ONLY

O F F

I N

O P M D Y

P = RC = No Yes

Dentist’s Name

Tax ID No. or SSN

City State Zip Code Reviewed By:

PAY

License Number National Provider Identification Number (NPI)

DENTAL CLAIM FORM Shaded Area is for Plan Use Only PLEASE TYPE OR PRINT

1. Identification Number 2. Group Number or Enrollment Code 3. Patient’s Name (First, Middle Initial, Last)

4. Patient’s Date of Birth 5. Patient’s Sex 6. Patient’s Relationship to Subscriber:

7. Subscriber’s Name (First, Middle Initial, Last) 8. Daytime Telephone Number (Include Area Code)

Subscriber’s Address (Street and Apt. or Box Number)

9. Is the patient covered under other dental insurance? OFFICE USE ONLY 10. Was patient’s condition due to:

Work related accident?

An auto accident?

Other accidental injury?

If yes, give the date of accident:

Please attach a statement with details indicating when, where and the manner in which the

injury occured.

Was another party at fault?

11.THIS CLAIM FORM MUST BE SIGNED. IF NOT, IT WILL BE RETURNED. I certify that the above

information is correct and apply for benefits under my dental coverage. I authorize any dentist

or physician in possession of information concerning the patient to furnish such information

upon request.

12.ASSIGNMENT OF BENEFITS: (Please see the reverse side of this form for further information.)

If "yes" block above is marked, I authorize the Blue Cross and Blue Shield Plan to pay

benefits directly to the provider of the services listed below.

The Plan may, at its discretion, accept or deny an assignment of benefits.

To be completed by Dentist

(See instructions on reverse.)

13.MISSING TEETH:

Identify missing teeth on chart with X. Indicate by tooth number,

the date each tooth was lost or extracted, if known:

14. ORTHODONTIA:

Is orthodontic treatment included in the services listed

below?

If yes, is this initial treatment?

15. CROWNS, BRIDGES AND DENTURES:

Do services include the replacement of a prosthesis (crown, bridge, denture)?

Indicate date of original placement or restoration and orignal teeth involved:

Reason for replacement:

See item 20 on the back of this form for x-ray requirements.

Identify Missing Teeth With “X”

16. Do charges include a consultation?

A report from the consulting specialist is required. See item 16 on the back of this form for additional information required for a consultation.

17. Description of Services (See instructions on reverse.)

Date of Service A.D.A. Procedure

Code Detailed Description of Services

Tooth No.or

Letter Surfaces

No. ofTimesPerf.

Place

Charge Other

Ins. Cons. Other

Ins. Paid

A D I

Remarks, Notes

18. Please check the appropriate box.

The treatment listed is necessary in my professional judgement and I

request Estimate of Eligible Benefits . Note: Dentist’s Tax ID Number or

Social Security Number is required.

I certify that the services have been performed by me or under my

personal supervision and are necessary in my professional judgement.

Charges shown are my usual charges.

19. TOTAL CHARGE 20. Are x-rays enclosed? (See item 20 on the back of this form.)

21.

CUT0131-1S 2/21

DENTAL CLAIM FORM GENERAL INFORMATION

Use this claim form to submit a claim for services which are covered under your dental program. To avoid delay in having your claim processed, please

complete a separate claim form for each patient, and be sure that all information is complete and correct. Items 1 through 12 of this form must be completed

by the subscriber or spouse, and items 13 through 21 are to be completed by the dentist.

When the claim form has been completed and signed, please mail it to your local Blue Cross and Blue Shield Plan.

INSTRUCTIONS FOR COMPLETING PATIENT AND SUBSCRIBER INFORMATION

Items 1-11: Complete all items as indicated on the front of the form.

Item 9: Please check yes or no in item 9. If yes, please provide information requested regarding your other dental insurance coverage. If payment has

been received from another insurance company, please attach a copy of their Explanation of Benefits.

Item 12: ASSIGNMENT OF BENEFITS - Benefits for services provided by participating dentists are made payable directly to the dentist, whether or not

benefits are assigned. Benefits for services provided by non-participating dentists located within our service area are made payable directly to

the subscriber, regardless of any assignment of benefits. However, if the non-participating dentist is located outside our service area and you

would like benefits due you for this claim sent directly to the dentist, complete item 12 on the reverse side of this form. Also, be sure the

dentist’s Tax ID Number or Social Security Number is included in item 21 with the dentist’s name and address.

INSTRUCTIONS FOR COMPLETING DENTIST INFORMATION

Item 13: MISSING TEETH - Each claim for services involving missing or extracted teeth must include the information requested in item 13. To assist

us in updating our records, with the submission of an initial oral exam, please include a complete charting of the patient’s dentition.

Item 14: ORTHODONTIA - Claims for orthodontic services must include the information requested in item 14. It is not necessary for the orthodontic

treatment to be completed before submitting the claim.

Item 15: CROWNS, BRIDGES AND DENTURES - Please complete this information on any claim for a crown, bridge or denture. See item 20 below for

x-ray requirements.

Item 16: CONSULTATIONS - Claims for consultations must include a report from the consulting specialist indicating the name of the referring dentist or

physician, the reason for the consultation, the treatment being considered and a description of the patient’s oral condition.

Item 17: ADA PROCEDURE CODES - American Dental Association codes

TOOTH NO. OR LETTER - Refer to tooth chart on front of this claim form.

SURFACES - Use the following codes to identify tooth surfaces:

B = Buccal or facial D = Distal O = Occlusal

M = Mesial I = Incisal L = Lingual

PLACE - Please check the appropriate column on the claim form to indicate the place of service:

Off = Office IN = Inpatient Hospital OP = Outpatient Hospital

CHARGE - Indicate the individual charge for each service listed.

Item 18: DENTIST’S CERTIFICATION AREA - Please check the appropriate box to indicate whether the services listed have been completed. The

dentist’s signature and telephone number must also be completed in item 18.

ESTIMATE OF ELIGIBLE BENEFITS - If no dates of service are indicated on the claim, we will provide an estimate of the benefits available

for the services listed. The estimates are based on the information we have at the time the claim is reviewed. Estimates will be subject to

eligibility, deductibles, and Plan maximums. Therefore, they may be affected by other payments made between the time the estimate is given

and the time that the services are rendered. Actual payments will be made in the order that the claims are received.

If you are requesting a Estimate of Eligible Benefits, mark the Estimate of Eligible Benefits box in item 18. In addition, the dentist’s name, address,

and Tax ID Number or Social Security Number must be clearly written in item 21 of this claim form.

Item 20: X-RAYS - Post-operative x-rays are required for the review of claims for root canals. These x-rays are also needed to review claims for posts

and cores following the root canals. Pre-operative x-rays are required for review of claims for crowns, crown build-ups, bridges, partial

dentures and apicoectomies. For periodontal procedures, we need the most recent pre-operative x-rays and complete periodontal charting of

the teeth involved in the treatment. We may also occasionally request x-rays for certain other procedures. All x-rays will be returned to the dentist

after the claim has been reviewed. To expedite the processing of your claim and to assist us in the return of the x-rays, please include the

patient’s name and identification number as well as the dentist’s name and address on the x-ray envelope.

Item 21: Each claim must include the dentist’s name, address and Tax ID Number or Social Security Number. Please also check the appropriate box in

item 21 to indicate the type of identification number used.

CUT0131-1S 2/21

Check if new address: OffSubscriber's address: Email Address: If yes name of other insurance: Name of Policy Holder: Other Policy ID Number: Work related accident?: OffAn auto accident?: OffOther accidental injury?: OffWas another party at fault?: OffTOOTH 1: DATE 1: TOOTH 2: DATE 2: TOOTH 3: DATE 3: TOOTH 4: Date appliance was placed: Expected completion date of orthodontic treatment: Total charge for active treatment: Tooth Numbers: If yes name of referring provider: Month_4: Day_4: Year_4: A: D: A: Procedure Code_1: Procedure Code_2: Procedure Code_3: Procedure Code_4: Procedure Code_5: Procedure Code_6: Procedure Code_7:

Detailed Description of Services_1: Tooth Number or Letter_1: Surfaces_1: Number of times performed_1: Place_1: OffCharge_1: Other Ins: Cons_1: Paid_1: Cons_2: Paid_2: Cons_3: Paid_3: Cons_4: Paid_4: Cons_5: Paid_5: Cons_6: Paid_6: Cons_7: Paid_7:

ADI_1: Remarks, Notes_1: Month_5: Day_5: Year_5: Detailed Description of Services_2: Tooth Number or Letter_2: Surfaces_2: Number of times performed_2: Place_2: OffCharge_2: ADI_2: Remarks, Notes_2: Month_6: Day_6: Year_6: Detailed Description of Services_3: Tooth Number or Letter_3: Surfaces_3: Number of times performed_3: Place_3: OffCharge_3: ADI_3: Remarks, Notes_3: Month_7: Day_7: Year_7: Detailed Description of Services_4: Tooth Number or Letter_4: Surfaces_4: Number of times performed_4: Place_4: OffCharge_4: ADI_4: Remarks, Notes_4: Month_8: Day_8: Year_8: Detailed Description of Services_5: Tooth Number or Letter_5: Surfaces_5: Number of times performed_5: Place_5: OffCharge_5: ADI_5: Remarks, Notes_5: Month_9: Day_9: Year_9: Detailed Description of Services_6: Tooth Number or Letter_6: Surfaces_6: Number of times performed_6: Place_6: OffCharge_6: ADI_6: Remarks, Notes_6: Month_10: Day_10: Year_10: Detailed Description of Services_7: Tooth Number or Letter_7: Surfaces_7: Number of times performed_7: Place_7: OffCharge_7: ADI_7: Remarks, Notes_7: P: RC: Are x-rays enclosed?: OffAddress_2: City_2: State_2: Zip Code_2: License number: National Provider Identification Number: Tax ID Number or SSN: Tax ID Number or SSN_1: Off1: Identification Number:

2: Group Number or Enrollment Code:

3: Patients Name First Middle Initial Last:

5: Patient's sex: Off

6: Patient's relationship to subscriber: Off Patient's relationship to subscriber, other, explain:

7: Subscribers Name First Middle Initial Last:

8: Daytime Telephone Number Include Area Code:

Subscriber's address, City: Subscriber's address, State: Subscriber's address, Zip Code: 9: Is the patient covered under dental insurance?: Off

Office use only, POI: Office use only, SOPL: 11: Date:

12: Assignment of benefits: Off Date:

14: Is orthodontic treatment included?: Off

If yes, is this initial treatment?: Off15: Do services include the replacement of a prosthesis?: Off If yes, what was the original prosthesis?: Reason for placement: Off Reason for placement, Other (explain): Date of original placement or restoration, Month, day, year:

16: Do charges include a consultation?: Off

18: Estimate of eligible benefits: Off Work completed - payment requested: Off Phone number:

19: TOTAL CHARGE: 0

21: Dentist's name:

Office use only, RPL: OffOffice use only, SPI: OffOffice use only, Reviewed By: Office use only, PAY: DATE 4: 4: Patient's Date of Birth, Month, day, year:

10: Date of accident, Month, day, year: