Delta Dental

P.O Box 997330

Customer Service 888-335-8227 Delta dental of California encourages Dental offices

Dental offices to submit claims electronically
Please type or print2. D not use a highlighter 3.staple X-rays to top right

Sacramento, California 958997330 www.deltadentalinis.com

1. Patients name

Relationship to spouse self spouse

3. child Other m

Sex f

4.Patients birthdate 5.Fulltime student over indicate Month Date Year School 5.Employers company, name and address Union local 19.Group number

City

Employee/ First Middle Last 7.SUBSCRIBER ID NUMBER Subscriber name SUBCRIBER MAILING APT NO. PHONE NO. ADDRESS CITY STATE

Subscriber birthday Month day

year

ZIP CODE 12.A NAME AND ADDRESS OF DENTAL CARRIERS,ITEM11. 12B.GROUP NUMBER 13. NAME AND ADDRESS OF EMPLOYER,ITEM 11

11.DOES PATIENT HAVE COVERAGE THROUGH ANOTHER COMPANY IF YES COMPLETE ITEMS12 THROUGH 15 YES NO 14A.SUBSCRIBER NAME, ITEM 11(OF DIFFERENT FROM PATIENTS) 16.DENTIST NAME

14B.SUBSCRIBER ID NUMBER LICENCE NUMBER

17.MAILING ADDRESS

14C. SUBSCRIBER BIRTHDATE 15.RELATIONSHIP TO PATIENT MONTH DAY YEAR SELF SPOUSE CHILD OTHER 24IS TREATEMENT RESULT OF NO YES IF YES, ENTER DATES, BRIEF DESCRIPTION AND ANY OCCUPATIONAL ILLNES OR AMOUNT PAID. INJURY? 25.IS TREATEMNT RESULT OF AN AUTO ACCIDENT 25. OTHER ACCIDENT?

CITY ,STATE ,ZIP

18.DENTIST SECURITY NUMBER OR T.I.N FIRST VISIT DATE CURRENT SERIES PLACE OF TREATMENT OFFICE

19.DENTIST LICENCE NUMBER 20.DENTIST PHONE NUMBER

identify missing teeth with x

23.RADIOGRA HOW NO YES IF SERVICE DATE APPLIANCES PLACED MOS. PHS OR MANY? A;READY TREATMENT HOSPITA ECF OTHER MODELS COMMENCED REMAINING L ENCLOSED ENTER NO YES 21. EXAMINATION AND TREATMENT RECORD-LIST IN ORDER FROM THE TOOTH NO. 1 THROUGH NO.32.USE CHARTING SYSTEM SHOWN TOOTH DESCRIPTION OF SERVICE INCLUDING DATE SERVICE PROCEDURE FEE NO.OR XRAYS, PROPHLAXIS MATERIALS USED ETC) COMPLETED NUMBER LETTER SURFACES M D Y

27. ARE ANY SERVICES COVERED BY A NONDENTAL PLAN? 28. IF PROSTHESIS IS THIS INITIAL REPLACEMENT? IF NO ENTER REASON FOR REPLACEMENT 30. IS TREATEMENT FOR OTHRORDONTICS?

29.DATE FOR PRIOR REPLACEMENT

32.REMARKS FOR UNUSUAL SERVICES OR AMOUNT PAID BY OTHER COVERAGE (ATTCH A COPY OF THR PRIMARY CARRIERS EXPLANATION OF BENEFITS)

My dentist may give Delta Dental and any other carrier named above information about my dental condition or treatment needed to determine benefits for up to 5years from the date Signature of patient. (or parent or guardian Date Pre-Treatment estimate The treatment is necessary in my professional judgment, and I request a pre-treatment estimate Dentist Signature Date

Total fee charged Patient pays TREATEMENT COMPLETED-PAYMENT REQUESTED THE TREATMENT LISTED WAS COMPLETED, I WILL CHANGE AND INTEND TO COLLECT THE ENTIRE PORTION OF THE FEES STATED ABOVE THAT DELTA DENTAL DETERMINES TO BE THE PATIENTS RESPONSIBILITY AND I WILL NOT WAIVE, REDUCE OR REBATE ANY OF THAT PORTION UNLESS I EXPRESSELY STATE ON THIS FORM Dentist Signature Date Delta Dental pays Amount applied to deductable