Form Jy0333-S - Dental Expense Claim
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1
2
3Dental Expense Claim
To Be Completed by Employee
1. Patient First Name
Middle
Last
2. Relationship to Employee
3. Sex
4. Married?
5. Patient Date of Birth
6. For Office Use
Mo. / Day / Year
Self
Spouse
Male
Yes
Child
Other
Female
No
7. If Full-Time Student (Age 19 or Over)
8. ID Number
9. If Disabled
10. Name of Group Dental Program
(Age 19 or Over)
School
City
State
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
16. Are other Family Members Employed?
Yes
No
17. Date of Birth
18. Name and Address of Employer for Item 16
Name
Social Security / ID Number
19. Is Patient Covered by Another Dental Plan?
Yes
No (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 Phone Number
26. Dentist License Number
27. Dentist SSN or T.I.N.
28. Provider Specialty Code
29. NPI (Treating Dentist)
30. NPI (Billing Entity, if different)
31. First Visit Date Current Series
32. Place of Treatment
33. Radiographs or Models Enclosed?
Office
Hospital
ECF
Other
Yes
No
How Many?
34. Is Treatment Result of Occupational Illness or Injury?
Yes
No
35. Is Treatment Result of Auto Accident?
Yes
No
(If Yes, Enter Brief Description and Dates)
(If Yes, Enter Brief Description and Dates)
36. Other Accident?
Yes
No
37. Are any Services Covered by Another Plan?
Yes
No
(If Yes, Enter Brief Description and Dates)
(If Yes, Enter Brief Description and Dates)
38. If Prosthesis, is this Initial Placement?
Yes
No (If No, Reason for Replacement)
39. Date of Prior Replacement
40. Is Treatment for Orthodontics?
If Services Already Commenced, Enter Date Appliance Placed
Months of Treatment Remaining
Yes
No
Dentist’s
Pretreatment Estimate
Statement of Actual Services (Be sure to sign below)*
41. 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.
42. I Hereby Certify That The Services Listed Above
Total Fee
*Signature of Dentist
Date Signed
Actually Charged
43. Address where treatment was performed
Street
City
State
Zip
JY0333-S (10/12)
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Parent category: Medical