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ADDRESS, CITY, STATE, ZIP (IF DIFFERENT THAN #39)43. Dental Office Toolkit What is the Dental Office Toolkit DOT is a portal where you get free, instant online claims processing and easy access to patient eligibility and benefit information 24/7. THE PROCEDURES WERE/ARE NECESSARY IN MYPROFESSIONAL JUDGEMENT.XSIGNED (TREATING DENTIST)DATE45. I HEREBY CERTIFY THAT I HAVE PERFORMED THE PROCEDURES AS INDICATED BY DATE AND/OR WISH TOPREDETERMINE THE PROCEDURES WHICH ARE NOT DATED. REPLACEMENT OF PROSTHESIS?YES DATE PRIOR PLACEMENT _BILLING DENTIST/DENTAL ENTITY (#40 - #43: USE FOR GROUP PRACTICE/MULTIPLE LOCATIONS) TREATING DENTIST AND LOCATION39. TREATMENT RESULTING FROM:OCCUPATIONAL ILLNESS/INJURY AUTO ACCIDENT OTHER ACCIDENTSUBSCRIBER SIGNATUREDATE38. IS TREATMENT RELATED TO ORTHODONTICS?NO YES DATE APPLIANCE PLACED _ MONTHS OF TREATMENT REMAINING _37. NUMBER OF ENCLOSURESRADIOGRAPHS _ DIGITAL IMAGES _ MODELS _36. PLACE OF TREATMENTDENTAL OFFICE HOSPITAL ECF OTHER35. IF PERMITTED, I HEREBY ASSIGN AND AUTHORIZE PAYMENT OF THE DENTAL BENEFITS OTHERWISEPAYABLE TO ME TO THE TREATING DENTIST.ADDITIONAL CLAIM INFORMATION34. AS PERMITTED UNDER LAW, I CONSENT TO THE USE AND DISCLOSURE OF MY PROTECTED HEALTHINFORMATION FOR PURPOSES OF PAYMENT OF THIS CLAIM.PATIENT/GUARDIAN SIGNATUREDATE33. FEE12345678910MISSING TEETH PERMANENT PRIMARY 29. IF PATIENT IS A DEPENDENT OVER AGE 19, PLEASE INDICATE STATUSFULL TIME STUDENT TOTALLY & PERM DISABLED IRS DEPENDENT SPONSORED DEPENDENTDENTAL SERVICES22. OTHER INSURANCE COMPANY/DENTAL BENEFIT PLAN NAME 21. RELATIONSHIP TO SUBSCRIBERSELF SPOUSE CHILD OTHER19. RELATIONSHIP TO PATIENTSELF SPOUSE CHILD OTHER18. PATIENT NAME (LAST, FIRST, MIDDLE INITIAL)8. SUBSCRIBER/POLICYHOLDER ID (SSN OR ID#) 17. SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL), ADDRESS, CITY, STATE, ZIP 12. SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL), ADDRESS, CITY, STATE, ZIP4. AMOUNT OF PRIMARY PAYMENT$DENTAL CLAIMSTATEMENTSUBSCRIBER INFORMATION11. BOX 9085FARMINGTON HILLS, MI 48333-9085OTHER COVERAGE3. OTHER DENTAL OR MEDICAL COVERAGE?NO IF NO, SKIP TO #11 YESDELTA DENTALP.O. STATEMENT OF ACTUAL SERVICES PREDETERMINATION REQUESTMAIL CLAIMS TO2.
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