Get UFT C-1259 2013-2024

L medical coverage School Telephone soc al ILLJ School or Bureau Sex SpouselDomestic Partner Social Security Number o ACTIVE MEMBER o RETIREE o COBRA PLEASE SUBMIT PRE-TREATMENT X-AAVS FOR NON-ROunNE EXTRACTIONS AND PREAND POST TREATMENT X-RAYS FOR ROOT MEMBER INFORMATION - See instructions on reverse side DENTAL FORM Refer Completed Claims and Questions to UFT Welfare Fund c/o Connecticut General Life Insurance Co. leM K D II 1-800-577-0576 SURGERY OR WHEN EXPENSES WIlL EXCEED 500 IN A 90 DAY PERIOD III Q Yes - Spouse/Domestic Partner UFT is a UFT Member therefore eligible for Special C. O. B. umro FEOERATD I Of TEACtiERS WElFARE RRtD lQO l* Z. N* EfICAIl FroEMTDH Of AA. O l CIGNA HcaltbCare Q PRE-TREATMENT ESTIMATE REQUIRED FOR INlAYS CROWNS* LAMINATE VENEERS BRIDGES DENTURES* PERIODONTAL o PAYMENT CLAIM CANAl* THERAPY I Birt date I Member Name Please Print Home Address City State se rity Zip Code i Telephone Do you have G*H. PO. Box 182531 Chattanooga TN 37422-7531 DYes No Name and Address of Other Company/Organization Providing Dental Benefits under which you are covered PATIENT INFORMATION Patient Name Please Print Relationship to Member SPOUSE/DOMESTIC PARTNER INFORMATION - Required if claim is for Spouse/Domestic Partner or Dependent Child I. S otise/Domestic Partner. 8Irthda Is spouse/domestic partner covered by another Dental Benefits Plan other than UFTWF o Yes o No If yes. specify below. Company/Organization Telephone AUTHORIZATION Authorization to release information must be signed or payment will not be made To Release Information I have reviewed the following treatment plan* I authorize release of any and all information relating to this claim* Signed Patient or Parent if Minor Date To Assign Benefits I hereby authorize payment directly to the below named dentist of the benefits otherwise payable to me. I understand I am financially responsible to the dentist for charges not covered by this assignment. This authorization is invalid unless the TAX 10 of the provider is given below. Signed Member DENTIST INFORMATION - See instructions on the back regarding the need for x-rays Dentist s Name please Print Street Address Taxpayer 10 II Ucense o Date of Prior Placement If prosthesis is this the initial placement 0 No If no. the reason for replacement DENOTE MISSING TEETH WITH AN X 115 this claim the result of Accident Injury 0 Yes 0 No Motor Vehicle Injury 0 Yes 0 No l PATIENT S NAME - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - i -------AGE Are radiographs enclosed If yes how many DVes Tooth or letter ONo Surtace Description of Service including materials used Date Service Performed Procedure Code I herllby certify thllllcourAcy of tho prll lrllAtmont Illitimlltlll lnd/or proC ld rlllllilnd if eomplotod the dliltelil of oompletion lllillitli d llbov i Was II pl 8 tl llfttment filled by llnother provldllr7 Q Ya C No Signed Dentist Oate C - 1259 5/13 1111111111 l1li1111 II TOTAL FEE CHARGED Fee. leM K D II 1-800-577-0576 SURGERY OR WHEN EXPENSES WIlL EXCEED 500 IN A 90 DAY PERIOD III Q Yes - Spouse/Domestic Partner UFT is a UFT Member therefore eligible for Special C. O. B. umro FEOERATD I Of TEACtiERS WElFARE RRtD lQO l* Z. N* EfICAIl FroEMTDH Of AA. O l CIGNA HcaltbCare Q PRE-TREATMENT ESTIMATE REQUIRED FOR INlAYS CROWNS* LAMINATE VENEERS BRIDGES DENTURES* PERIODONTAL o PAYMENT CLAIM CANAl* THERAPY I Birt date I Member Name Please Print Home Address City State se rity Zip Code i Telephone Do you have G*H. .