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Ent of Actual Services OR Request for Predetermination / Preauthorization EPSDT/ Title XIX PRIMARY SUBSCRIBER INFORMATION 2. Predetermination / Preauthorization Number 12. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code PRIMARY PAYER INFORMATION 3. Name, Address, City, State, Zip Code 15. Subscriber Identifier (SSN or ID#) 14. Gender 13. Date of Birth (MM/DD/CCYY) M OTHER COVERAGE 16. Plan/Group Number 4. Other Dental or Medical Coverage? F 17. E.

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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.

  1. Click the ‘Get Form’ button to obtain the Dental Claim 2013 Form and open it in the editor of your choice.
  2. Start by filling in the header information. Please send the completed claim form to the dental claim address found on your plan identification card.
  3. 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'.
  4. For section 2, input your Predetermination/Preauthorization Number, if applicable.
  5. In section 12, fill out the name (last, first, middle initial, suffix), address, city, state, and zip code of the primary subscriber.
  6. Complete section 3 with the primary payer's name, address, city, state, and zip code.
  7. Provide the subscriber identifier (SSN or ID#) in field 15, the gender in field 14, and the date of birth in field 13.
  8. 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.
  9. For section 5, enter the subscriber's name, date of birth, subscriber identifier, and gender.
  10. Continue by specifying the relationship to the primary subscriber in section 18.
  11. Proceed to the record of services provided section (item 24 to 34), detailing each procedure's date, tooth involved, surface, code, description, and fee.
  12. Mark each missing tooth as indicated in section 34. List all applicable fees in section 32.
  13. Complete the authorizations and acknowledgement sections, ensuring to have the required signatures in place.
  14. 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.

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Nov 3, 2014 — the NPI in Item 32a of the CMS-1500 claim form or on the ANSI X12 837...
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Questions & Answers

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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.

If you seek compensation from a dentist, the first step is to communicate your concerns directly with the dentist's office. If the issue remains unresolved, you may need to gather documentation and submit a Dental Claim 2013 Form through your insurance for potential compensation based on your dental plan.

To claim back dental costs, ensure you fill out the Dental Claim 2013 Form accurately. Attach your payment receipts and any other necessary information. Submit your claim based on your insurance provider's instructions for efficient processing.

To submit a dental claim to the VA, you should start by obtaining the Dental Claim 2013 Form. You'll need to fill it out with the necessary details about your treatment and attach any supporting documents. Once completed, send it to the address specified by the VA for processing.

Claiming back dental expenses begins with completing the Dental Claim 2013 Form. Once you have your claim form ready, attach your receipts and any additional required documentation. Submit your claim according to your insurance provider’s guidelines for reimbursement.

To claim back on dental expenses, you typically need to fill out a Dental Claim 2013 Form provided by your insurer. After completing the form, submit it along with any necessary documentation, such as receipts or treatment records. Always keep copies for your records to follow up if needed.

To submit a claim to DeCare Dental, you'll need to complete the Dental Claim 2013 Form and include any required documentation, such as receipts and treatment details. After filling out the form, you can send it through their designated claims submission process, which may include mailing or electronic submission options. Ensuring you follow the specific requirements will help expedite the processing of your claim. Using USLegalForms can simplify accessing the correct forms and instructions.

The primary purpose of a claim form is to allow individuals to request compensation from their insurance company for services rendered. This form provides a structured way to communicate necessary details about the dental care you received. Completing the Dental Claim 2013 Form helps streamline this communication, making it easier for insurers to process your request. Effective use of this form can lead to timely reimbursements.

A dental claim form is a document patients or dental providers fill out to request payment for dental services from insurance companies. This form outlines the specific procedures performed, the associated costs, and information about the patient and provider. Completing the Dental Claim 2013 Form accurately can increase the likelihood of quicker reimbursement. Our online resources can help guide you through the process.

The Dental Claim 2013 Form is the standard form used for submitting dental claims to insurance companies. This form includes sections for detailing services rendered, provider information, and patient details. It's crucial to use the correct form to help facilitate the claims process. Utilizing our platform, USLegalForms, ensures you access the appropriate versions of this form easily.

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© Copyright 1997-2026
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Your Privacy Choices
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Help Portal
Legal Resources
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
altaFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2026
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232