Dentist'S Claim Form
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1
2UNITED CONCORDIA
DENTIST'S CLAIM FORM
Form Approved
TRICARE Dental Program
OMB No. 0720-0035
Claims Processing
Dentist's pre-treatment estimate
Check
Expires Jan. 31, 2013
P.O. Box 69411
One:
Dentist's statement of actual services
Harrisburg, PA 17106-9411
1. Patient name
2. Relationship to sponsor
3. Sex
4. Patient birthdate
5. If full-time student
self
spouse
child
other
mo
day
year
school
city
m
f
6. Sponsor's name
11. Branch of service
P
Middle
Last
First
A
T
12. Group name
7. Sponsor's Social Security number (SSN)
I
TRICARE Dental Program
E
N
8. Patient mailing address
13. Is patient covered by
Dental plan name
another dental plan?
T
no
yes
City, State, Zip
Insured name and Subscriber Identifier (SSN or ID#)
Group no.
S
E
9. Telephone number
Name and address of carrier
C
T
I
10. I have reviewed the following treatment plan. I authorize release of any
14. I hereby authorize payment of my group insurance benefits, otherwise payable to me, to
O
information relating to this claim.
the dentist listed below.
N
Signature (patient or parent if minor)
Date
Signature (insured person)
Date
15. Dentist name
15a. Provider no.
23. Is treatment result
No Yes
If yes, enter brief description and dates
D
of occupational
E
illness or injury?
N
16. Mailing address–street address
24. Is treatment result
T
of auto accident?
I
25. Other accident?
S
City, State, Zip
26. If prosthesis, is
(If no, reason for replacement)
27. Date of prior
T
placement
this initial
placement?
S
17. Dentist SSN or T.I.N.
18. Dentist license no.
19. Dentist phone no.
28. Is treatment for
Appliance insertion date
Total length of treatment
E
orthodontics?
C
T
20. First visit date
21. Place of treatment
22. Radiographs and/
No Yes How
29. Transfer patient?
If yes, reband date
If no, starting date of
I
treatment
current series
Office
Hosp.
ECF
Other
Many?
or documentation
O
enclosed?
Was patient rebanded?
N
30. Examination and treatment plan—list in order from Tooth No. 1 through Tooth No. 32—Use charting system shown.
DATE SERVICE
TOOTH
DESCRIPTION OF SERVICES
PROCEDURE
FEE
PERFORMED
NO. OR
SURFACE
(INCLUDING X-RAYS, PROPHYLAXIS, MATERIALS USED, ETC.)
CODE
CHARGED
LETTER
MO.
DAY
YR.
32. TOTAL FEE
MISSING TEETH INFORMATION
Permanent
Primary
CHARGED
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
31. Place an 'X' on each missing tooth
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
33. Remarks for unusual services
34. PAYMENT OR
COPAY OF
OTHER PLAN
35. 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.
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 Practice.
Signature (Dentist)
Date
5578 G 02/10
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