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Get Dental Claim 2013 Form
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How to fill out the Dental Claim 2013 Form online
Filling out the Dental Claim 2013 Form online can be a straightforward process when guided through each component. This guide provides simple, step-by-step instructions to help users complete the form accurately and efficiently.
Follow the steps to complete your Dental Claim 2013 Form online.
- Click the ‘Get Form’ button to obtain the Dental Claim 2013 Form and open it in the editor of your choice.
- Start by filling in the header information. Please send the completed claim form to the dental claim address found on your plan identification card.
- In section 1, indicate the type of transaction by checking all applicable boxes. You may choose between 'Statement of Actual Services' or 'Request for Predetermination/Preauthorization'.
- For section 2, input your Predetermination/Preauthorization Number, if applicable.
- In section 12, fill out the name (last, first, middle initial, suffix), address, city, state, and zip code of the primary subscriber.
- Complete section 3 with the primary payer's name, address, city, state, and zip code.
- Provide the subscriber identifier (SSN or ID#) in field 15, the gender in field 14, and the date of birth in field 13.
- In section 4, indicate if there is other dental or medical coverage. If yes, complete sections 5 through 11; if no, skip to section 12.
- For section 5, enter the subscriber's name, date of birth, subscriber identifier, and gender.
- Continue by specifying the relationship to the primary subscriber in section 18.
- Proceed to the record of services provided section (item 24 to 34), detailing each procedure's date, tooth involved, surface, code, description, and fee.
- Mark each missing tooth as indicated in section 34. List all applicable fees in section 32.
- Complete the authorizations and acknowledgement sections, ensuring to have the required signatures in place.
- Review all sections for accuracy. Once completed, you can save changes, download, print, or share the form as needed.
Take the next step in managing your dental claims by completing and submitting your Dental Claim 2013 Form online.
To claim back dental treatment, use the Dental Claim 2013 Form that corresponds to your insurance policy. Make sure to include all relevant receipts and documentation to support your claim. Submit your completed form as instructed by your insurance provider to start the reimbursement process.
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