Dental Claim Form CONTINENTAL AMERICAN Form.pdf · Dental Claim Form ©American Dental Association, page 1
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Dental Claim Form CONTINENTAL AMERICAN Form.pdf · Dental Claim Form ©American Dental Association,

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Text of Dental Claim Form CONTINENTAL AMERICAN Form.pdf · Dental Claim Form ©American Dental Association,

  • Dental Claim Form American Dental Association, 1999 version 2000

    American Dental Association, 1999

    1. Dentists pre-treatment estimateDentists statement of actual services

    Specialty (see backside) 3. Carrier Name

    4. Carrier Address2. Medicaid ClaimEPSDT

    Prior Authorization #

    5. City 6. State 7. Zip

    8. Patient Name (Last, First, Middle) 9. Address 10. City 11. State

    12. Date of Birth (MM/DD/YYYY)

    / /

    13. Certificate # 14. Sex

    M F

    15. Phone Number( )

    16. Zip Code



    17. Relationship to Certificateholder/Employee:

    Self Spouse Child Other_____________________________________

    18. Employer

    Name____________________________ Address________________________

    19. Pol.Hldr./Emp. ID#/SSN# 20. Employer Name 21. Group # 31. Is Patient covered by another plan

    No (Skip 3237) Yes: Dental or Medical

    32. Certificate #

    22. Certificateholder/Employee Name (Last, First, Middle) 33. Other Certificateholders Name

    23. Address 24. Phone Number( )

    34. Date of Birth (MM/DD/YYYY)

    / /

    35. Sex

    M F

    36. Plan/Program Name

    25. City 26. State 27. Zip Code OTH

    ER P




    37. Employer/School

    Name________________________________ Address_____________________

    28. Date of Birth (MM/DD/YYYY)

    / /

    29. Marital Status

    Married Single Other

    30. Sex

    M F

    38. Certificateholder/Employee Status

    Employed Part-time Status Full-time Student Part-time Student

    40. Employer/School

    Name_______________________________ Address______________________POLCER



    ER /




    39. I have been informed of the treatment and associated fees. I agree to be responsible for allcharges for dental services and materials not paid by my dental benefit plan, unless the treatingdentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of suchcharges. To the extent permitted under applicable law, I authorize release of any information relatingto this claim.

    X____________________________________________________________________Signed (Patient/Guardian) Date (MM/DD/YYYY)

    41. I hereby authorize payment of the dental benefits otherwise payable to me directly to thebelow named dental entity.

    X_______________________________________________________________Signed (Employee/certificateholder) Date (MM/DD/YYYY)

    42. Name of Billing Dentist or Dental Entity 43. Phone Number( )

    44. Provider ID # 45. Dentist Soc. Sec. or T.I.N.

    46. Address 47. Dentist License # 48. First visit date of current


    49. Place of treatment

    Office Hosp. ECF Other

    50. City 51. State 52. Zip Code 53. Radiographs or models enclosed?

    Yes, How many?_______ No

    54. Is treatment for orthodontics? Yes No

    If service already commenced:

    55. If prosthesis (crown, bridge, dentures), is this

    initial placement? Yes No

    If no, reason for replacement:


    Date of prior placement:


    Date appliances placed


    Total mos. of treatment

    remaining __________BIL


    G D




    56. Is treatment result of occupational illness or injury? No Yes

    Brief description and dates___________________________________

    57. Is treatment result of: auto accident? other accident? neither

    Brief description and dates__________________________________________________

    58. Diagnosis Code Index (optional) 1. ________________ 2. ________________ 3. ________________ 4. ________________ 5. ________________ 6. ________________ 7. ________________ 8. ________________

    59. Examination and treatment plans List teeth in order

    Date (MM/DD/YYYY) Tooth Surface Diagnosis Index # Procedure Code Qty Description FeeAdmin. Use Only

    60. Identify all missing teeth with XPermanent Primary

    Total Fee

    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I J Payment by other plan

    32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T S R Q P O N M L K Max. Allowable

    Deductible 61. Remarks for unusual services

    Carrier %

    Carrier pays

    Patient pays

    63. Address where treatment was performed62. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) orhave been completed and that the fees submitted are the actual fees I have charged and intend to collect for thoseprocedures.

    X _________________________________________________________________________________Signed (Treating Dentist) License # Date (MM/DD/YYYY)

    64. City 65.State 66. Zip Code


    e11965Text Box

    e11965Text Box

    e11965Text Box

    e11965Text Box

    e11965Text Box

    e11965Text Box

    e11965Text Box

    e11965Text BoxToll-Free:1-866-849-0017 Fax:1-866-849-2970

    e11965Text Box

    e11965Typewritten TextCAI1001DENTAL-12v2

    e11965Typewritten Text

    e11965Typewritten Text


    Dear Certificateholder/Claimant: Enclosed is a claim form for filing for dental benefits. Please have the claim form completed as follows: FILING FOR DENTAL BENEFITS:

    1. Please complete the Patient section, boxes 8-18. 2. Please complete the Certificateholder/Employee section. Excluding boxes 31-38 and 40. 3. Please have your dentist complete the Billing Dentist section, Boxes 42- 66.

    Excluding box 53.

    Processing time for a routine claim is 10 business days. Failure to have this form properly completed may delay processing of your claim. Please mail completed form to the address noted in boxes 3 through 7. You may fax your completed claim to 1-866-849-2970. Should you have any questions, please do not hesitate to contact the Customer Service Center at 1-866-849-0017.

    e11965Typewritten Text

  • Phone (800) 433-3036 Fax (866) 849-2970

    CAIC-H4/03 HIPAA Privacy Rule rev. 7/11

    INSURED_____________________________________________ COVERAGE ID/CERTIFICATE NUMBER________________________________


    CONTINENTAL AMERICAN INSURANCE COMPANY For the purpose of evaluating my eligibility for insurance and eligibility for benefits under an existing policy/certificate, including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application for coverage and/or claim form, I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Continental American Insurance Company (CAIC) and its duly authorized representatives.

    Disclosure of Health Information

    Health information may be disclosed by any health care provider, health plan (including CAIC with respect to other CAIC or coverages) or health care clearinghouse that has any records or knowledge about me. Health care provider includes, but is not limited to, any licensed physician, medical or nurse practitioner, nurse, pharmacist, osteopath, psychologist, physical or occupational therapist, chiropractor, dentist, audiologist or speech pathologist, podiatrist, hospital, medical clinic or laboratory, pharmacy, rehabilitation facility, nursing home or extended care facility, prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Financial or credit history, earnings, or employment history may be disclosed by any entity, person, or organization that has these records about me, including but not limited to my employer, employer representative and compensation sources, insurance company, financial institution, or any consumer reporting agency. Federal, state, and local government organizations including but not limited to the Veterans Administration, Internal Revenue Service, Social Security Administration, and Medicare or Medicaid agencies, may disclose health or financial information or records about me. Any information CAIC obtains pursuant to this authorization will be used for the purpose of evaluating and administering my application for coverage and/or claim for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. CAIC will not disclose the information unless permitted or required by those laws. I understand that if the information disclosed is protected health information relating to a health plan and the person or entity receiving the information is a not a health care provider or health plan covered by federal privacy regulations, the information disclosed may be redisclosed by such person or entity and will likely no lo