United healthcare dental claim form 2025

1. Click ‘Get Form’ to open the united healthcare dental claim form in the editor.
2. Begin by filling out the header information, including the type of transaction. Check all applicable boxes for Statement of Actual Services or Request for Predetermination/Preauthorization.
3. In the Primary Subscriber Information section, enter the subscriber's name, address, date of birth, and gender. Ensure that you include the subscriber identifier (SSN or ID#).
4. Complete the Patient Information section by providing details about the patient, including their relationship to the primary subscriber and any other coverage information.
5. Record services provided by entering procedure dates, tooth numbers, procedure codes, and fees in the Record of Services Provided section.
6. Fill out any missing teeth information as required and provide necessary authorizations and signatures at the end of the form.

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