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
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Is the member the same as the patient?
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
Rows 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
- Dental Information
- Primary Complaint
- Date symptoms presented
  MonthDayYear
  Date
- What are the symptoms provided by the patient?
- Based on the dental history of the patient, did the patient previously undergoes dental/gum/orthodontic treatment for the same symptoms or related?
- Please provide details of the past dental/gum/orthodontic treatment
- Diagnosis
- Is/Are there missing tooth/teeth? If yes, then kindly select the appropriate position.
- Dental Provider Details (Clinic/Dentist)
- Dentist Name
  First NameLast Name
- Clinic Name
- Clinic Phone Number
  Format: (000) 000-0000.
- Clinic Email
  example@example.com
- Clinic Address
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- Dentist Signature
  Clear
- Date Signed
  MonthDayYear
  Date
- Should be Empty:

Select theme:

Rows	Date	Diagnosis	Treatment	Medications	Others	Total Charge
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9

Dental Medical Claim Form

Member Information

Patient Information

Claim Details

Dental Information

Dental Provider Details (Clinic/Dentist)