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Blue dental claim form

Blue dental claim form 2025

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The document is a Dental Claim Form used to submit claims for dental services covered under a dental insurance program. It requires detailed patient and subscriber information, including identification numbers, relationship to the subscriber, and coverage details. The form also includes sections for the dentist to provide information about services rendered, missing teeth, orthodontic treatment, and necessary documentation such as X-rays. Proper completion of the form is essential for timely processing of claims.

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Click ‘Get Form’ to open the blue dental claim form in the editor.
Begin by filling out the Identification Number and Group Number or Enrollment Code in the first two fields. Ensure accuracy as this information is crucial for processing your claim.
Complete the Patient’s Name, Date of Birth, and Sex fields. Select the appropriate relationship of the patient to the subscriber from the options provided.
Enter the Subscriber’s Name, Address, and Daytime Telephone Number. If there is a new address, check the corresponding box.
Indicate if the patient has other dental insurance coverage and provide details if applicable. This helps avoid delays in processing your claim.
Sign and date the form where indicated to certify that all information is correct. Remember, without a signature, your claim may be returned.
For dentist-related sections (items 15-23), ensure that your dentist completes these accurately before submission.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (55 Votes)
2020	4.4 Satisfied (134 Votes)
2020	4.7 Satisfied (51 Votes)
2020	4.3 Satisfied (26 Votes)
2020	4.2 Satisfied (36 Votes)
2020	4.8 Satisfied (101 Votes)
2020	4.8 Satisfied (261 Votes)
2020	4.8 Satisfied (117 Votes)
2020	4.8 Satisfied (247 Votes)
2019	4.8 Satisfied (130 Votes)
2019	4.8 Satisfied (54 Votes)
2019	4.8 Satisfied (51 Votes)
2019	4.8 Satisfied (142 Votes)
2019	4.8 Satisfied (35 Votes)
2019	4.8 Satisfied (171 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Does Alberta Blue Cross cover any dental?

Basic dental services covered include the following: Cleanings and preventative services, such as polishing and scaling. Restorative services, such as fillings and trauma or pain control. Extractionsboth simple and complicated. Root canals (endodontics).

How do I submit to Alberta Blue Cross dental?

Your dental claims may be submitted online through the member website, or you may download a PDF Dental claim form and mail it, with your receipts, to Alberta Blue Cross.

Is Alberta Blue Cross the same as Blue Cross?

Like the five other Blue Cross plans in Canada, ABC Benefits Corporation operates the Alberta Blue Cross Plan in compliance with the licensing requirements of the Canadian Association of Blue Cross Plans.

How to file a BCBS dental claim?

Download and fill out the claim form at bcbsfepdental.com/claimform. Log in to the secure member portal at bcbsfepdental.com. Head to the My Documents tab, click Submit a Claim and select the claim form you saved. Make sure you only submit one claim form at a time and any supporting documents.

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.

blue shield dental claim form

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Do Blue Cross and Blue Shield of Texas cover dental?

Our dental plans provide coverage for preventive services like oral exams, cleanings and routine X-rays, as well as procedures like fillings, bridges and crowns. Youll have access to the largest dental network in the United States.

How do I submit a claim to DeCare dental?

For claim or benefit queries, contact the DeCare Dental customer support team on 1890 130 017 or 094 93 78608. Section D may list treatments that are not covered by your particular dental policy. Please refer to your Schedule of Benefits and Terms and Conditions Booklet for full details of your cover.