Dentist/'s Statement Of Actual Services Dentist/'s Pre Treatment ...
Check One
Dentist's pre-treatment estimate
Please submit claim to: Dental Claims
Dentist's statement of actual services
P.O. Box 69421
Harrisburg, PA 17106-9416
1. Patient name
2. Relationship to employee
3. Sex
4. Patient birth date
5. If full time student
self
spouse
child
other m f
mo day year
school
city
6. Employee/subscriber name
9. Contract ID #
P
First
middle
last
AT 8. Employee/subscriber mailing address
10. Employer (company) name and address
IEN City, State, Zip
T
11. Group Number 12. Location (Local) 13. Are other family members employed?
14. Name and address of employer in item 13
Employee name
Contract ID #
S
E 15. Is patient covered by
Dental plan name
Union local
Group no.
Name and address of carrier
C
another dental plan?
TI I have reviewed the following treatment plan. I authorize release of any information relating to I hereby authorize payment directly to the below name dentist of the group insurance benefits
this claim. I understand that I am responsible for all costs of dental treatment.
otherwise payable to me.
O
N
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Date
The signer agrees that any personally identifiable health information about the signer or signer's enrolled dependents is protected by the Health Insurance Portability and Accountability Act of 1996 and other privacy laws. In
accordance with those laws, United Concordia may use and disclose Protected Health Information for treatment, payment and health care operations as described in its Notice of Privacy Practices.
D 16. Dentist name
24. Is treatment result
No Yes
If yes, enter brief description and dates
of occupational
E
illness or injury?
N
T 17. Mailing address
25. Is treatment result
of auto accident?
IS
26. Other accident?
T
City, state, zip
27. Are any services
covered by
S
another plan?
E 18. Dentist soc. sec. or T.I.N.
19. Dentist license no.
20. Dentist phone no.
28. If prosthesis, is
(If no, reason for replacement)
29. Date of prior
C
this initial
placement
T
placement?
I 21. First visit date
22. Place of treatment
23. Radiographs or
No Yes How
If services
Date appliances placed
Mos. treatment
current series
Office Hosp. ECF Other
O
models enclosed?
Many? 30. Is treatment for
already
remaining
orthodontics?
commenced
N
enter
Identify missing teeth
31. Examination and treatment plan-list in order from Tooth No. 1 through Tooth No. 32 - Use charting system shown.
Use charting
system shown
FOR
with "X"
TOOTH
DESCRIPTION OF SERVICES
DATE SERVICE
PROCEDURE
ADMINISTRATIVE
NO. OR
SURFACE
(INCLUDING X-RAYS, PROPHYLAXIS, MATERIALS USED,ETC.)
PERFORMED
CODE
FEE
LETTER
LINE NO.
USE ONLY
MO. DAY YR.
I hereby certify that 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.
TOTAL
FEE
Signature (Dentist)
Date
CHARGED
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.
CA:
For your protection California law requires that the following appear on the form: Any person who knowingly presents a false claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement
in state prison.
DC:
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.
FL:
Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the third degree.
NJ:
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
NY:
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.
LA:
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.
IN & OK: WARNING: Any person who knowingly and with intent to injure, defraud or deceive an insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a
felony.
VA:
Any person who within 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 may have violated the state law.
TN & WA: 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.
5574WEB (R11-09)
