Dental Medical Claim Form

Dental Medical Claim Form
Note: Please complete this form accurately and make sure that required fields are filled to avoid delay in processing the claim.
Date Filed
MonthDayYear
Date
Member Information
Policy Number
Full Name
First NameMiddle NameLast Name
Age
Date of Birth
MonthDayYear
Date
Gender
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Is the member the same as the patient?
YesNo
Patient Information
Full Name
First NameMiddle NameLast Name
Age
Date of Birth
MonthDayYear
Date
Gender
Relationship to the member
Claim Details
Consultation Date
MonthDayYear
Date
Patient Complaint
Claim Information
Date Diagnosis Treatment Medications Others Total Charge
1
2
3
4
5
6
7
8
9
Total Amount
Member/Patient Signature
Clear
Date Signed
MonthDayYear
Date

Member Information