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MEMBER DENTAL CLAIM FORMPlease type or print
1. Identification Number 2. Group Number 3. Patients name
(First, Middle Initial, Last)
4. Patients Date of Birth 5. Patients Sex 6. Patients
Relationship to Subscriber:
Month Day Year Female c Self c Child c
_____/______/_____ Male c Spouse c Other c Explain:
7. Subscribers Name (First, Middle Initial, Last) 8. Daytime
Telephone Number (include Area Code)
Subscribers Address (Street and Apt. or Box Number)
City State Zip Code
9. Is the patient covered under other dental insurance?
No c Yes c
If yes, name of insurance: _____________________________
Name of Policy Holder _________________________________
Other Policy ID Number ________________________________
10. Was patients condition due to:
Work related accident? No c Yes cAn auto accident? No c Yes
cOther accidental injury? No c Yes c
If yes, give the date of accident _____/______/_____Mo. Day
Year
Please attach a statement with details indicating when, where
and the manner in which the injury occurred.
Was another party at fault? No c Yes c
11. ORTHODONTIA:
Is orthodontic treatment included in the services listed
below?
No c Yes c
If yes, is this initial treatment? No c Yes c
Date appliance was placed:
______________________________________________________________________________
Expected completion date of orthodontic treatment:
_________________________________________________________
Total charges for active treatment
_________________________________________________________________________
12. THIS CLAIM FORM MUST BE SIGNED, IF NOT, IT WILL BE
RETURNED.
I certify that the above information is correct and apply for
benefits under my dental coverage with CareFirst BlueCross
BlueShield or CareFirst BlueChoice. I authorize any dentist or
physician in possession of information concerning the patient to
furnish such information to CareFirst BlueCross BlueShield or
CareFirst BlueChoice upon request.
Any person who knowingly or willfully presents a false or
fraudulent claim for payment of a loss or benefit or who knowingly
or willfully presents false information in an application for
insurance is guilty of a crime and may be subject to fines and
confinement in prison.
______________________________________________________________________
_______________Signature of Subscriber or Spouse Date
CUT0167-1S (04/16)CareFirst BlueCross BlueShield is the shared
business name of CareFirst of Maryland, Inc. and Group
Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and
The Dental Network are independent licensees of the Blue Cross and
Blue Shield Association. Registered trademark of the Blue Cross and
Blue Shield Association.
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13. CROWNS, BRIDGES AND DENTURES:
Do services include the replacement of prosthesis (crown,
bridge, denture)? No c Yes c
If yes, what was the original prosthesis? Mo. Day Year Tooth
Number(s)
Indicate date of original placement or restoration and original
teeth involved: _____/______/______ ____________
Reason for replacement: Original Damaged c Lost or Stolen c
Other c
(Explain)
_______________________________________________________See item 17
of the instructions for X-ray requirements
14. ASSIGNMENT OF BENEFITS: (See instruction page.) The Plan
may, at its discretion, accept or deny an assignment of
benefits.
No c Yes c
If yes block above is marked, I authorize CareFirst BlueCross
BlueShield or CareFirst BlueChoice to pay benefits directly to the
provider of the services listed.
_____________________________________________________
___________________Signature of Subscriber or Spouse Date
15. DESCRIPTION OF SERVICES (See instructions on reverse.)
Date of Service
A.D.A. Procedure Code
Detailed Description of Services Tooth No. or Letter
Surfaces # Times Perf.
Charge
M D Y
16. TOTAL
CHARGES..............................................................................................................................................
17. ARE X-RAYS ENCLOSED?
No c Yes c (See Instructions page.)
18. PLEASE CHECK APPROPRIATE BOX
c ESTIMATE OF ELIGIBLE BENEFITSThe treatment listed is necessary
in my professional judgement and I request an Estimate of Eligible
Benefits.NOTE: Dentists Tax ID Number or Social Security Number is
required
c WORK COMPLETED PAYMENT REQUESTEDI certify that the above
services have been performed by me or under my personal supervision
and are necessary in my professional judgement. Charges shown are
my usual charges.
Dentists Signature Phone #
19.
Dentist Name c Tax ID No. or c SSN
Address City State Zip Code
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MEMBER DENTAL CLAIM FORMInstructions
Use this claim form to submit a claim for services, which may be
covered under your dental program. To avoid delay in having your
claimprocessed, please complete a separate claim form for each
patient, and ensure that all information is complete and correct.
We will returnthe form to you for the information if each question
is not answered. Items 1 through 19 of this form must be
completed.
Item 1-19:Complete all items as indicated on the front form.
Item 9:Please check yes or no in item 9. If yes, please provide
information regarding your other dental insurance coverage. If
payment has beenreceived from another company, please attach a copy
of their Explanation of Benefits.
Item 11:ORTHODONTIA - Claims for orthodontic services must
include the information requested in item 14. It is not necessary
for the orthodontictreatment to be completed before submitting the
claim.
Item 13:CROWNS, BRIDGES, AND DENTURES - Please complete this
information on any claim for a crown, bridge or denture. See item
17 below forX-ray requirements.
Item 14:ASSIGNMENT OF BENEFITS - Benefits for services provided
by participating dentists are made payable directly to the dentist,
whether ornot benefits are assigned. Benefits for services provided
buy non-participating dentist located within our service area are
made payabledirectly to the subscriber, regardless of any
assignment of benefits (except for Virginia non-participating
providers when benefits have beenassigned).
Item 15:DATE OF SERVICE - Month, day and year of services were
rendered.ADA PROCEDURE CODES - Most recent American Dental
Association codes.TOOTH NUMBERS - 1 to 32 for permanent dentition,
A to T for primary (deciduous) dentition.SURFACES - Use the
following codes to identify tooth surfaces: B = Buccal or facial D
= Distal O = Occlusal M = Mesial I = IncisalL = LingualCHARGE -
Indicate the individual charge for each service listed.
Item 17:X-rays are needed to review claims for posts and cores
following root canals. Pre-operative X-rays are required for review
of claims forcrowns and bridges. For periodontal procedures, we
need the mot recent pre-operative X-rays and complete periodontal
charting of theteeth involved in the treatment. We may also
occasionally request X-rays for certain other procedures. All
X-rays will be returned to thedentist after the claim has been
reviewed. To expedite the processing of your claim and assist us in
the return of the X-rays, please includethe patients name and
identification number as well as the dentists name and address on
the X-ray envelope.
Item 18:DENTISTS CERTIFICATION AREA Please check the appropriate
box to indicate whether the services listed have been completed.
Thedentists signature and telephone number must also be completed
in item 18.
ESTIMATE OF ELIGIBLE BENEFITS If no dates of service are
indicated on the claim, we will provide an estimate of the benefits
availablefor the services listed. The estimates are based on the
information we have at the time the claim is reviewed. Estimates
will be subject toeligibility, deductibles, and Plan maximums.
Therefore, they may be affected by other payments made between the
time the estimate isgiven and the time that the services are
rendered. Actual payments will be made in the order that the claims
are received.If you are requesting an Estimate of Eligible
Benefits, mark the Estimate of Eligible benefits box in item 18. In
addition, the dentists address,and Tax ID Number or Social Security
Number must be clearly written in item 19 of this claim form.
Item 19:Each claim must include a bill (on letterhead
stationary) with the dentists name, address and Tax Identification
Number or Social SecurityNumber. Please also check the appropriate
box in item 19 to indicate the type of identification number used.
Please keep copies; billscannot be returned.
When the claim form has been completed and signed, please mail
it to:
Mail AdministratorP.O. Box 14115Lexington, KY 40512-4115
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CareFirst BlueCross BlueShield is the shared business name of
CareFirst of Maryland, Inc. and Group Hospitalization and Medical
Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization
and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care,
Inc. and The Dental Network are independent licensees of the Blue
Cross and Blue Shield Association. Registered trademark of the Blue
Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
Notice of Nondiscrimination and Availability of Language
Assistance Services
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and
all of their corporate affiliates (CareFirst) comply with
applicable federal civil rights laws and do not discriminate on the
basis of race, color, national origin, age, disability or sex.
CareFirst does not exclude people or treat them differently because
of race, color, national origin, age, disability or sex.
CareFirst:
Provides free aid and services to people with disabilities to
communicate effectively with us, such as: o Qualified sign language
interpreters o Written information in other formats (large print,
audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language
is not English, such as: o Qualified interpreters o Information
written in other languages
If you need these services, please call 855-258-6518. If you
believe CareFirst has failed to provide these services, or
discriminated in another way, on the basis of race, color, national
origin, age, disability or sex, you can file a grievance with our
CareFirst Civil Rights Coordinator. Civil Rights Coordinator,
Corporate Office of Civil Rights Telephone Number 410-528-7820
Mailing Address P.O. Box 8894 Baltimore, Maryland 21224
Fax Number 410-505-2011
Email Address [email protected] You can file
a grievance by mail, fax or email. If you need help filing a
grievance, our CareFirst Civil Rights Coordinator is available to
help you. You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights
electronically through the Office for Civil Rights Complaint
portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at: U.S. Department of Health and Human Services 200 Independence
Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
800-368-1019, 800-537-7697 (TDD) Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
mailto:[email protected]://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html
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CareFirst BlueCross BlueShield is the shared business name of
CareFirst of Maryland, Inc. and Group Hospitalization and Medical
Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization
and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care,
Inc. and The Dental Network are independent licensees of the Blue
Cross and Blue Shield Association. Registered trademark of the Blue
Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
Foreign Language Assistance Attention (English): This notice
contains information about your insurance coverage. It may contain
key dates
and you may need to take action by certain deadlines. You have
the right to get this information and assistance in
your language at no cost. Members should call the phone number
on the back of their member identification card.
All others may call 855-258-6518 and wait through the dialogue
until prompted to push 0. When an agent
answers, state the language you need and you will be connected
to an interpreter.
(Amharic) -
855-258-6518 0
d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt
o s le n lti
gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf.
wn m-gb
gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o
s dr npas jrr
tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m
gbuf kan.
Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo
him ca qu v. Thng bo c th
cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh.
Qu v c quyn nhn
c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh
vin nn gi s in thoi
mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v
ch ht cuc i thoi cho
n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu
v cn v qu v s c
kt ni vi mt thng dch vin.
Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng
impormasyon tungkol sa nasasaklawan ng iyong
insurance. Maaari itong maglaman ng mga pinakamahalagang petsa
at maaaring kailangan mong gumawa ng
aksyon ayon sa ilang deadline. May karapatan ka na makuha ang
impormasyong ito at tulong sa iyong sariling
wika nang walang gastos. Dapat tawagan ng mga Miyembro ang
numero ng telepono na nasa likuran ng kanilang
identification card. Ang lahat ng iba ay maaaring tumawag sa
855-258-6518 at maghintay hanggang sa dulo ng
diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot
ang ahente, sabihin ang wika na kailangan mo
at ikokonekta ka sa isang interpreter.
Espaol (Spanish) Atencin: Este aviso contiene informacin sobre
su cobertura de seguro. Es posible que
incluya fechas clave y que usted tenga que realizar alguna accin
antes de ciertas fechas lmite. Usted tiene
derecho a obtener esta informacin y asistencia en su idioma sin
ningn costo. Los asegurados deben llamar al
nmero de telfono que se encuentra al reverso de su tarjeta de
identificacin. Todos los dems pueden llamar al
855-258-6518 y esperar la grabacin hasta que se les indique que
deben presionar 0. Cuando un agente de seguros
responda, indique el idioma que necesita y se le comunicar con
un intrprete.
(Russian) !
. ,
.
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.
855-258-6518 , 0.
, .
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CareFirst BlueCross BlueShield is the shared business name of
CareFirst of Maryland, Inc. and Group Hospitalization and Medical
Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization
and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care,
Inc. and The Dental Network are independent licensees of the Blue
Cross and Blue Shield Association. Registered trademark of the Blue
Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
(Hindi) : - 855-258-6518 0 ,
s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu
a-fa-tiin ny je dyi. B nia k
ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b
nia k ke gbo-
kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a
fn-na nia e waa
I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo
tee wa ke m gbo c m ke
na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po
dyi, ke ny o mu o niin
ke ni wuu mu za.
(Bengali) : 855-258-6518 0
: (Urdu )
0 6518-258-855
: . (Farsi ). .
.
. 0 855-258-6518
.
: (Arabic) . .
.
.0 855-258-6518
.
(Traditional Chinese)
855-258-6518
0
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CareFirst BlueCross BlueShield is the shared business name of
CareFirst of Maryland, Inc. and Group Hospitalization and Medical
Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization
and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care,
Inc. and The Dental Network are independent licensees of the Blue
Cross and Blue Shield Association. Registered trademark of the Blue
Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe
g. nwere ike nwe bch nd d
mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta
ozi na enyemaka a nass g na
akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad
njirimara ha. Nd z niile nwere
ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe
onye nnchite anya zara, kwuo
ass chr, a ga-ejik g na onye kwa okwu.
Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen
ber Ihren Versicherungsschutz. Sie kann
wichtige Termine beinhalten, und Sie mssen gegebenenfalls
innerhalb bestimmter Fristen reagieren. Sie haben
das Recht, diese Informationen und weitere Untersttzung
kostenlos in Ihrer Sprache zu erhalten. Als Mitglied
verwenden Sie bitte die auf der Rckseite Ihrer Karte angegebene
Telefonnummer. Alle anderen Personen rufen
bitte die Nummer 855-258-6518 an und warten auf die
Aufforderung, die Taste 0 zu drcken. Geben Sie dem
Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem
Dolmetscher verbinden kann.
Franais (French) Attention: cet avis contient des informations
sur votre couverture d'assurance. Des dates
importantes peuvent y figurer et il se peut que vous deviez
entreprendre des dmarches avant certaines chances.
Vous avez le droit d'obtenir gratuitement ces informations et de
l'aide dans votre langue. Les membres doivent
appeler le numro de tlphone figurant l'arrire de leur carte
d'identification. Tous les autres peuvent appeler le
855-258-6518 et, aprs avoir cout le message, appuyer sur le 0
lorsqu'ils seront invits le faire. Lorsqu'un(e)
employ(e) rpondra, indiquez la langue que vous souhaitez et vous
serez mis(e) en relation avec un interprte.
(Korean) : . .
. ID .
855-258-6518 0 .
.