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 ...

Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. Any updates to these instructions will be posted on the ...

2. You must sign the claim form under the Patient Information section indicating that the information is correct and authorizing payment. 3.

In addition, the dentist's name, address,and Tax ID Number or Social Security Number must be clearly written in item 23 of this claim form. Item 22 ...

Member Submitted Dental Claim Form. Use this form to request reimbursement for covered supplemental dental services that have been completed and paid in full ...

37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity.

Ask your dentist to complete Sections 2 and 3, and sign the claim form; or attach an original itemized superbill. 3. All bills must include the following:.

EMPLOYER'S INSURANCE COMPANY. POLICY OR CONTRACT NUMBER. DENTAL CLAIM FORM. EMPLOYEE. SURNAME. ADDRESS. CITY, PROVINCE. PATIENT. DATE RECEIVED. CONTRACT NUMBER.

Submit a claim only when you're billed for services from a provider who doesn't directly submit a claim to the local Blue Cross Blue Shield plan.

Being a standard form, this form cannot include specific instructions on where it should be sent, depending on who is the carrier for your plan.