Dental Claim Form Please complete entire form. Mail Claims to: PAI, PO Box 6702, Columbia, SC 29260 Employer/Plan Name: Dental Provider: Covered Person: Complete Part 1, sign the authorization, and.
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How to fill out the Po Box 6702 Columbia Sc 29260 online
Filling out the form that is sent to Po Box 6702 Columbia, SC 29260 can be straightforward if you follow the proper steps. This guide provides clear and concise instructions to help you complete the form correctly and efficiently.
Follow the steps to complete the form online
- Press the ‘Get Form’ button to access the form for completion. This will allow you to open the document in an editable format.
- Begin with Part 1, where the employee must fill in their details. Provide your full name, including last, first, and middle names. Then, enter your social security number and birth date. Additionally, indicate whether you are a full-time student.
- Complete the relationship section by selecting how the patient is related to you. If you are the patient, mark 'self'. Enter your address accurately, including street, city, state, and ZIP code.
- Indicate if the patient is covered by another dental plan and provide the name and group number of that plan, if applicable.
- Sign the authorization section to allow the dentist to process your claim. Make sure to date your signature.
- If you are signing on behalf of a minor, also provide your relationship to the insured and any necessary documentation to establish your legal authority.
- Once Part 1 is fully completed, save your progress. You may then proceed to Part 2, where the dentist must fill out additional details about the treatment provided.
- Finally, review the filled form to confirm all sections are accurate and complete. Once satisfied, you can save changes, download the document, print it, or share it as required.
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PLANNED ADMINISTRATORS. PO BOX 6702. COLUMBUS. SC. 29260-0000 ... 7821. SRC STRATEGIC...
803.822.6702 ... P.O. Box 2408. Columbia, SC 29202 (803) 822-3749 eoc@midlandstech.edu...
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