Dental Insurance Claim Form Pdf

Information to be included in a dental claim form.

Dental insurance claim form pdf. Jy0333 k 08 18 page 1 of 5 fs f. First name middle name last name 2. The form is designed so that the name and address item 3 of the third party payer receiving the claim insurance company dental benefit plan is visible in a standard 9 window envelope window to the left. See item 20 on the back of this form for x ray requirements.

Name of policy holder other policy id number identify missing teeth with x to be completed by dentist see instructions on reverse 1 identification number 4. Please fold the form using the tick marks printed in the margin. To be completed by employee. Insurance or statement of claim containing deliberately false information commits a fraudulent insurance act which is a crime.

This will include the policyholder or insured member s name address date of birth and contact details it will also include information about the dental insurance plan such as the policy number. Dental expense claim. Dental claim form patient s details to be completed by the beneficiary or his her legal representative 1 patient name 2 policy id 3 patient s date of birth. Enter your official identification and contact details.

The advanced tools of the editor will lead you through the editable pdf template. Metropolitan life insurance company. The form is designed so that the name and address item 3 of the third party payer receiving the claim insurance company dental benefit plan is visible in a standard 9 window envelope window to the left. Central time monday through friday by phone 800 621 8099.

No yes if yes name of other insurance. For office use 7. To start the blank use the fill sign online button or tick the preview image of the form.