Dental Expense Claim - Metlife - Lancaster General Health
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1
2Metropolitan Life Insurance Company
Dental Expense Claim
To Be Completed by Employee (You must review the important statements on page 2 and sign where indicated before completing this section of the form.)
1. Patient First Name
Middle
Last
2. Relationship to Employee
3. Sex
4. Married?
5. Patient Date of Birth
6. For Office Use
Self
Spouse
Child
Male
Yes
Mo. / Day / Year
Other
Female
No
7. If Full Time Student (Age 19 or Over)
8. EMPLOYEE Social Security / ID Number
9. If Disabled
10. Name of Group Dental Program
School
City
State
(Age 19 or Over)
Lancaster General
Yes
No
11. Employee First Name
Middle
Last
12. Employee Date of Birth
13. Office Phone (Area Code)
14. Employee Residence Mailing Address
15. City, State, Zip
Yes
No
17. Date of Birth
18. Name and Address of Employer for Item 16
16. Are other Family Members Employed?
Name
Social Security / ID Number
Yes
No
19. Is Patient Covered by Another Dental Plan?
(If Yes, complete the following:)
Dental Plan Name
Group No.
Name and Address of Carrier
20. I Authorize Release of any Information Relating to this Claim.
21. I Certify that the Above Information is Correct.
22. I Authorize Payment Directly to the Below Named Dentist.
(Signature of Patient or Signature of Authorized
Date
Representative if Minor)
Employee Signature
Date
Employee Signature
Date
If Authorized Representative, Relationship to Minor
To Be Completed by Dentist
23. Dentist Name
24. Mailing Address
City
State
Zip
25. Dentist Social Security Number or T.I.N.
26. Dentist License Number
27. Dentist Phone Number
28. First Visit Date Current Series
29. Place of Treatment
30. Radiographs or Models Enclosed?
Office
Hospital
ECF
Other
Yes
No How Many?
Yes
No
Yes
No
31. Is Treatment Result of Occupational Illness or Injury?
32. Is Treatment Result of Auto Accident?
(If Yes, Enter Brief Description and Dates)
(If Yes, Enter Brief Description and Dates)
Yes
No
Yes
No
33. Other Accident?
34. Are any Services Covered by Another Plan?
(If Yes, Enter Brief Description and Dates)
(If Yes, Enter Brief Description and Dates)
Yes
No
36. Date of Prior Replacement?
35. If Prosthesis, is this Initial Placement?
(If No, Reason for Replacement)
37. Is Treatment for Orthodontics?
If Services Already Commenced, Enter
Date Appliance Placed
Months of Treatment Remaining
Yes
No
Dentist’s −
Pre-treatment Estimate
Statement of Actual Services (Be sure to sign below)*
38. Examination and Treatment Plan – List in Order From Tooth #1 through Tooth #32 (Use Charting System Shown)
Tooth #
Date Service
ADA
Description of Services
For Carrier
or
Surface
Performed
Procedure
Fee
(Including X-Rays, Prophylaxis, Materials Used, Etc.)
Use Only
Letter
Mo./ Day /Year
Number
Will Be
Have Been Performed
39. I Hereby Certify That The Services Listed Above
Total Fee
*Signature of Dentist
Date
Actually Charged
40. Address where treatment was performed
Street
City
State
Zip
Page 1 of 2
JY0333 (07/03)
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