Form Gc-8-29 - Dental Benefits Claim Instructions And Dental Benefits Request Form Page 2
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1
2Mail to: SRC, an Aetna Company
Dental Benefits Request
Attn: Claim Department
P.O. Box 23759
Columbia, SC 29224-3759
Fax to: 1-803-333-1402
Phone: 1-888-772-9682
TO BE COMPLETED BY EMPLOYEE
1. Employer's Name
2. Policy/Group Number
3. Employee's Aetna ID Number
4. Employee's Name
5. Employee's Birthdate (MM/DD/YYYY)
6.
Active
Retired
7. Employee's Address (include zip code)
Address is new
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 Sex
15. Full Time Student
16. Patient's Expected Graduation Date 17. Name of School
City
Male
Female
No
Yes
18. Patient's Marital Status
19. Is patient employed?
20. Name & Address of Employer
Married
Single
No
Yes
21. Is claim related to an accident?
22. Is claim related to employment?
No
Yes
No
Yes
If yes, date
time
am
pm
23. Are any family members’ expenses covered by another group health plan, group pre-payment plan (Blue
24. If yes, list policy or contract holder, policy or contract number(s) and name/address of
Cross- Blue Shield, etc.), no fault auto insurance, Medicare or any federal, state or local government plan?
insurance company or administrator:
No
Yes
25. Member’s ID Number
26. Member’s Name
27. Member’s Birthdate (MM/DD/YYYY)
To all providers of dental care:
.
28
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
I authorize payment of dental benefits to the dentist or supplier of service.
29.
Patient's or Authorized Person's Signature
Date
TO BE COMPLETED BY DENTIST
30. This is a request for:
Request for Pre-Treatment Estimate Predetermination/Preauthorization Number
Statement of Services Rendered
31. Dentist's Name & Address (include zip code)
32. National Provider Identifier
33. Dentist License No.
34. Telephone Number
(
)
35. 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
.
36. First Visit Date Current Series
37. Place of Treatment
38. Radiographs or models enclosed?
Office
Hosp.
No
Yes
ECF
Other
How many?
Is treatment result of:
No
Yes If yes, enter brief description and dates
39.
occupational illness or injury?
40.
auto accident?
41.
other accident?
42. Are any services covered by another plan?
43. If prosthesis, is this initial placement?
If no, date of prior placement and reason for replacement
44. Is treatment for orthodontics?
Date appliance placed:
Initial Appliance Fee:
No. of months of treatment:
Monthly Fee:
Mos. of treatment remaining:
Total Case Fee:
45. 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"
Tooth #
If Previously
Surface
Description of Service (x-rays, prophylaxis, materials
Date Service Performed
Procedure
Fee
or Letter
Extracted, Give Date
used, etc.)
MM
DD
YYYY
Number
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I hereby certify that the procedures as indicated by date have been completed and that the fees
48. National Provider Identification
47.
Total charge $
submitted are the actual fees I have charged this patient and intend to accept for those
procedures.
Amount paid $
Balance due $
Dentist's Signature
Date
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