Dentist Claim Form
Patient Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Insurance Information
Insurance Provider
Description of Treatment
CPT Code(s)
Tooth Number(s)
Provider Information
Dentist's Name
First Name
Last Name
Dental Practice Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
NPI (National Provider Identifier)
Cost Breakdown
Treatment Cost $
Diagnostic Costs $
Lab Fees $
Total Claim Amount $ (Calculated Automatically)
Payment Information
Preferred Payment Method
Please Select
Check
Electronic Transfer,
Billing Contact Information
Attach X-rays or Supporting Documents
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Patient Consent
I hereby authorize the release of my dental information for the purpose of processing this claim.
Submit
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