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Get Za Denis Insurance Administrators Dental Insurance Claim Form Elite Plan

Ractice Details Dentist Name Date of Visit Practice no Section C: Diagnosis Detail PLEASE NOTE: Only the benefit claimed for in the blue section below will be processed and if it is not completed then this claim will be declined automatically. It is also compulsory to submit a valid statement or quote with your claim. DIAGNOSIS: Gingivitis Likely Treatment Scale & Polish Tooth decay or abscess-poor prognosis of rehabilitation Extraction Tooth decay- good prognosis of rehabilitation Fil.

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