Dental Claim Form

ATTENDING DENTIST’S STATEMENT
CHECK ONE: USE ONE FORM PER CLAIM

MAIL TO:
) STATEMENT OF ACTUAL SERVICES

) PRE-TREATMENT ESTIMATE

PATIENT INFORMATION

1. PATIENT NAME
FIRST

M.I.BLUE CROSS AND BLUE SHIELD OF ILLINOIS
POST OFFICE BOX 23059
BELLEVILLE, ILLINOIS 62223-0059

2. RELATIONSHIP TO EMPLOYEE
) SELF
) CHILD
) SPOUSE
) OTHER

LAST

3. SEX
)M
)F

6.EMPLOYEE/SUBSCRIBER NAME AND MAILING ADDRESS

4. PATIENT BIRTH DATE
MO. / DAY / YEAR

5. IF FULL-TIME STUDENT
SCHOOL
CITY
8. EMP/SUB BIRTH DATE
MO. / DAY / YEAR

7. EMPLOYEE/SUBSCRIBERIDENTIFICATION NUMBER

9. EMPLOYER (COMPANY) NAME AND ADDRESS

10. GROUP NO.

11. IS PATIENT COVERED BY ANOTHER PLAN? IF YES, COMPLETE BOXES 12A THRU 15.
DENTAL: ) YES ) NO
MEDICAL: ) YES ) NO

12-A.NAME AND ADDRESS OF CARRIER(S)

12-B. GROUP NUMBER(S)

13. NAME AND ADDRESS OF EMPLOYER

14-A. OTHER EMPLOYEE/SUBSCRIBER NAME (IF DIFFERENT THAN PATIENT’S)

14-B. EMPLOYEE/SUBSCRIBERIDENTIFICATION NUMBER

14-C. EMPLOYEE/SUBSCRIBER BIRTH DATE
MO. / DAY / YEAR

15. RELATIONSHIP TO PATIENT

) SELF

) CHILD

) SPOUSE

) OTHER

I UNDERSTAND THAT BLUE CROSS AND BLUE SHIELD’S USE ORDISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH
INFORMATION, WHETHER FURNISHED BY ME OR OBTAINED FROM OTHER SOURCES SUCH AS MEDICAL PROVIDERS, SHALL
BE IN ACCORDANCE WITH THE FEDERAL PRIVACYREGULATIONS UNDER HIPAA (HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT OF 1996). I AUTHORIZE RELEASE OF ANY INFORMATION RELATING TO THIS CLAIM. I UNDERSTAND
THAT I AM RESPONSIBLE FOR ALL COSTS OFDENTAL TREATMENT.

I HEREBY AUTHORIZE PAYMENT OF THE DENTAL BENEFITS OTHERWISE PAYABLE TO ME DIRECTLY TO THE
BELOW NAMED DENTAL ENTITY.

SIGNED (PATIENT, OR PARENT IF MINOR)

SIGNED (INSUREDPERSON)

DATE

DENTIST INFORMATION

16. DENTIST NAME

24. IS TREATMENT RESULT OF
OCCUPATIONAL ILLNESS OR INJURY?

17. MAILING ADDRESS

DATE
NO

YES IF YES, ENTER BRIEF DESCRIPTION AND...