Form Gc-16474 - Dental Benefits Request And Dental Benifits Claim Instructions - 2016
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1
2Dental Benefits Request
Mail to: Aetna Dental
PO Box 14094
Lexington, KY 40512-4094
877-512-0363
TO BE COMPLETED BY EMPLOYEE – USE BLACK INK ONLY
1. Employer's Name
2. Policy/Group Number
Johnson & Johnson Family of Companies
865445
3. Employee's Aetna ID Number or SSN
4. Employee's Name
5. Employee's Birthdate (MM/DD/YYYY)
6.
Active
Retired
7. Employee's Address (include ZIP Code)
8. Employee's Daytime Telephone Number
(
)
Date of Retirement
9. Patient's Name
10. Patient's Aetna ID Number
11. Patient's Birthdate (MM/DD/YYYY)
12. Patient's Relationship to Employee
Self
Spouse
Child
Other
13. Patient's Address (if different from employee)
14. Patient's Gender
15. Is patient employed?
Male
Female
No
Yes
16. Name and Address of Employer
17. Is claim related to an accident?
18. Is claim related to employment?
No
Yes
No
Yes
If Yes, date
time
am
pm
19. Are any family members’ expenses covered by another group health plan, group pre-payment plan (Blue
20. If Yes, list policy or contract holder, policy or contract number(s) and
Cross- Blue Shield, etc.), no fault auto insurance, Medicare or any federal, state or local government plan?
name/address of insurance company or administrator:
No
Yes
21. Member’s ID Number
22. Member’s Name
23. Member’s Birthdate (MM/DD/YYYY)
24. To all providers of dental care:
You are authorized to provide Aetna Life Insurance Company or one of its affiliated companies (“Aetna”), and any independent claim administrators and consulting dental professionals
and utilization review organizations with whom Aetna has contracted, information concerning dental care, advice, treatment or supplies provided the patient. This information will be used
to evaluate claims for dental benefits. Aetna may provide the employer named above with any benefit calculation used in payment of this claim for the purpose of reviewing the
experience and operation of the policy or contract. This authorization is valid for the term of the policy or contract under which a claim has been submitted. I know that I have a right to
receive a copy of this authorization upon request and agree that a photographic copy of this authorization is as valid as the original.
Patient's or Authorized Person's Signature
Date
25. I authorize payment of dental benefits to the dentist or supplier of service.
Patient's or Authorized Person's Signature
Date
TO BE COMPLETED BY DENTIST – USE BLACK INK ONLY
26. This is a request for:
Pre-Treatment Estimate
Predetermination/Preauthorization Number
Statement of Services Rendered
27. Dentist's Name & Address (include ZIP Code)
28. National Provider Identifier
29. Dentist License No.
30. Telephone Number
(
)
31. Enter the taxpayer identifying number to be used for 1099 reporting purposes. You are required under authority of
law to furnish your taxpayer identifying number.
32. First Visit Date Current Series
33. Place of Treatment
34. Radiographs or models enclosed?
Office
Hosp.
No
Yes
ECF
Other
How many?
Is treatment result of:
If Yes, enter brief description and dates.
No
Yes
35.
occupational illness or injury?
36.
auto accident?
37.
other accident?
38. Are any services covered by another plan?
39. If prosthesis, is this initial placement?
If No, date of prior placement and reason for replacement.
40. Is treatment for orthodontics?
Date appliance placed:
Initial Appliance Fee:
No. of months of treatment:
Monthly Fee:
Mos. of treatment remaining:
Total Case Fee:
41. To expedite claim handling, identify
46. Examination and treatment plan. List in order from tooth no. 1 through tooth no. 32. Use charting system shown.
all missing teeth with "X"
If Previously
Date Service
Tooth #
Extracted,
Description of Service (x-rays, prophylaxis,
Performed
Procedure
or Letter
Give Date
Surface
materials used, etc.)
MM
DD
YYYY
Number
Fee
42. I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the
43. National Provider Identification Total charge $
actual fees I have charged this patient and intend to accept for those procedures.
Amount paid $
Dentist's Signature
Date
Balance due $
GC-16474 (1-16) V1 J&J
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