2012 dental claim form-2025

1. Click ‘Get Form’ to open the 2012 dental claim form in the editor.
2. Begin by filling out the header information. Indicate the type of transaction by selecting one of the three options: 'Statement of Actual Services', 'Request for Predetermination/Preauthorization', or 'EPSDT/Title XIX'.
3. Enter the insurance company or dental benefit plan details, including name, address, and contact information. This is crucial for processing your claim.
4. In the 'Other Coverage' section, mark if there are additional dental or medical plans. Complete relevant fields about policyholders and their coverage.
5. Fill in patient information accurately, including name, date of birth, and relationship to the policyholder. Ensure all details match those on insurance documents.
6. Document services provided by entering procedure dates, codes, descriptions, and fees in the 'Record Of Services Provided' section.
7. Finally, review all entries for accuracy before signing off on patient consent and authorizations at the end of the form.

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