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Click ‘Get Form’ to open the dc37 dental form in the editor.
In the Policy Holder/Subscriber section, complete all required fields from boxes #4 to #23. Ensure that all information is accurate to avoid processing delays.
If you are the member, patient, or guardian of a minor, fill out box #36 by providing the date and either your signature or indicating 'signature on file.'
Complete box #37 to authorize payment directly to your dentist.
For the dentist section, enter all necessary details including your social security number or tax ID and full address.
List all procedures and fees separately in the treatment area. Include tooth numbers, quadrant codes, and total amounts in box #32. Only CDT codes are accepted in column #29.
Attach any required mounted x-rays along with your request for pre-authorization or claims for completed services.
To expedite processing, submit claims electronically via Secure EDI at https://www.secureedi.com/securetrack/home.aspx or send paper claims to DC 37 Health and Security Plan at 125 Barclay Street, New York, N.Y. 10007.

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What is a dental claim form?

The ADA Dental Claim Form provides a common format for reporting dental services to a patients dental benefit plan. ADA policy promotes use and acceptance of the most current version of the ADA Dental Claim Form by dentists.

Why would a dental claim be denied?

Claims are often denied when dental work is performed under the assumption of coverage that isnt actually included in your plan. Provide correct personal information: Misspelling personal information when filling out a dental insurance claim form can lead to claim denial.

How to file a dental claim?

For all claims, full receipts are required and must show: The name of the person receiving treatment and making the claim. The name of the dentist/practitioner performing the treatment. FULL details of all treatment received. Confirmation of payment (a separate debit credit/debit card voucher will be accepted)

What is a dental claim form for?

The ADA Dental Claim Form provides a common format for reporting dental services to a patients dental benefit plan. ADA policy promotes use and acceptance of the most current version of the ADA Dental Claim Form by dentists and payers.

What is the purpose of a claim form?

Claim forms are used when you want to recover compensation for the cost of the property damage sustained in a car accident. To recover damages, your car accident attorney will draft a demand letter.