Form Gc-14423 - Aetna Dentist'S Statement printable pdf download

Aetna Global Benefits

Dentist's Statement

Coverage underwritten by Aetna Life Insurance Company

and Aetna Life & Casualty (Bermuda) Ltd.

! This form should be completed and submitted if an itemized bill is

! If this is for a pre-treatment estimate, leave the date blank for those

services that have not been completed. Our estimate and your X-rays will

not provided to accompany the Claim Form (GR-68069) and/or if

be returned to you promptly. Estimates are subject to deductible and plan

treatment is for other than an examination, cleaning or x-rays. The

maximums and may be reduced by payments made before these

Summary of Reimbursement section of the Dental Benefit Request

services are rendered. The estimate is based on the assumption the

form will identify the party to whom benefit payments should be

patient will receive the services while covered and the treatment plan

made payable/sent.

does not change. Actual payment may differ from the estimate.

! Fully itemized bills and receipts should include: Patient's name and

relationship to employee, Provider Name/address/telephone number,

Indicate date of treatment only when treatment has been completed.

condition being treated, date of service, type of service rendered and the

Describe any changes in the treatment plan.

tooth or teeth affected by treatment, amount charged, and procedures

! Submit X-rays with:

performed. If this information is not shown, you may hand-write it on the

request for pre-treatment estimates

bill/receipt and sign your name.

treatments involving gold restorations, crowns, implants or

! If fully itemized bills are not provided or if services rendered are for other

bridgework.

than examinations, cleanings or x-rays, Provider's should complete this

! X-rays may be requested for other service.

form and attach it to all bills and a completed Claim Form (GR-68069),

! Identify any missing teeth and date extracted on the tooth chart below.

and mail them to the address on the back of the member's insurance

Identification Card or Aetna Global Benefits, P.O. Box 30258,

Tampa, FL 33630-3258, U.S.A.

1. Employee's Name

2. Employee's Social Security/I.D. Number

3. Patient's Name

4. Patient's Birthdate (mm/dd/yyyy)

5. This is a

Request for pre-treatment estimate

Statement of services rendered

6. Dentist's Name & Address (include zip code)

7. Telephone No.

8. Dentist License No.

(

)

9. If applicable, enter the taxpayer identifying number to be used for U.S. 1099 reporting purposes.

You are required under authority of U.S. law to furnish your taxpayer identifying number.

10. First Visit Date Current

11. Place of Treatment

12. Radiographs or models

Series

Office

Hosp.

enclosed?

Yes

ECF

Other

How many?

Is treatment result of:

Yes

If yes, enter brief description and dates

13.

occupational illness or injury?

14.

auto accident?

15.

other accident?

16. Are any services covered by another plan?

17. If prosthesis, is this initial placement?

If no, date of prior placement and reason for replacement

18. Is treatment for orthodontics?

Date appliance placed:

Initial Appliance Fee:

No. of months of treatment:

Monthly Fee:

Mos. of treatment remaining:

Total Case Fee:

19. To expedite claim handling,

20. Examination and treatment plan. List in order from tooth no. 1 through tooth no. 32.

Use charting system shown.

identify all missing teeth with "X"

Tooth #

If Previously

Surface

Description of Service (x-rays,

Date Service

Procedure

Fee

Extracted,

prophylaxis, materials used, etc.)

Performed

Number

Letter

Give Date

(mm/dd/yyyy)

21. I hereby certify that the procedures as indicated by date have been completed and that the fees submitted

Total charge $

are the actual fees I have charged this patient and intend to accept for those procedures.

Amount paid $

Dentist's Signature

Date

Balance due $

Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include

imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to claim was provided by the applicant.

California Residents: For your protection, California law requires notice of the following: Any person who knowingly and with intent to defraud or deceive any

insurance company files a statement of claim containing any materially false, incomplete or misleading information is guilty of a crime and may be subject to

fines, confinement in a state prison and substantial civil penalties.

Colorado Residents: An insurer or agent who knowingly provides false or misleading information to defraud a claimant regarding insurance

proceeds must be reported to the Insurance Division.

Pennsylvania Residents: 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.

Please Retain A Copy For Your Records

GC-14423 (11-04) A-POD