ATTENDING DENTIST’S STATEMENT	UCI

MAIL ORIGINAL TO: ►

SF 4400-DEN (6-2004)

Supersedes (8-2002) issue

P.O. Box 9085

Farmington Hills, Michigan 48333-9085

MARK (X) APPROPRIATE BOX
PLEASE TYPE AL REQUIRED INFORMATION

SEE NEXT PAGE FOR INSTRUCTIONS	Protect this form as sensitive when information is entered.	DENTIST’S STATEMENT OF ACTUAL SERVICES	DENTIST’S PRE-DETERMINATION REQUEST
PATIENT & SUBSCRIBER INFORMATION
1. Patient Name First, Last, Middle Name	2. PATIENT

RELATIONSHIP

TO SUBSCRIBER	SELF	SPOUSE	CHILD	OTHER	3. PATIENT SEX	4. PATIENT BIRTHDATE

MM DD CC/YY
MALE	FEMALE
5. SUBSCRIBER NUMBER	6. SUBSCRIBER BIRTHDATE

MM DD CC/YY	7. GROUP NUMBER	8. IF PATIENT IS A DEPENDENT OVER 19, PLEASE INDICATE STATES
9550
FULL TIME STUDENT
TOTALLY & PERM DISABLED
IRS DEPENDENT
SPONSORED DEPENDENT
9. SUBSCRIBER NAME FIRST	LAST	MIDDLE INITIAL	8a	ONLY FOR STATUS ALLOWING ASSIGNMENT (SEE REVERSE): I HEREBY ASSIGN AND
AUTHORIZE PAYMENT OF THE GROUP DENTAL BENEFITS OTHERWISE PAYABLE TO ME TO

THE BELOW NAMED DENTIST, AND SIGN ON LINE 11.
10. SUBSCRIBER MAILING ADDRESS

11. SUBSCRIBER SIGNATURE	DATE
12. CITY

STATE

ZIP CODE

13. EMPLOYER / COMPANY NAME

IF PATIENT IS COVERED BY ANOTHER PLAN, COMPLETE ITEMS 14-24

14. SUBSCRIBER NAME FIRST LAST MIDDLE INITIAL	15. OTHER SUBSCRIBER NUMBER	16. BIRTH DATE

MM DD CC/YY	17. GROUP NUMBER	18. AMOUNT OF PRIMARY PAYMENT
$
19. MAILING ADDRESS

22. NAME OF OTHER CARRIER

20. CITY

STATE

ZIP CODE

23. CARRIER ADDRESS

21. NAME OF EMPLOYER

24. CITY

STATE

ZIP CODE

PROVIDER INFORMATION
25. PROVIDER BUSINESS NAME

26. PROVIDER TAX IDENTIFICATION NUMBER

27. SERVICE OFFICE ADDRESS (NAME / STREET)

28. DDS LIC. NO.

29. STATE

30. SPEC. CD.

31. CITY

STATE

ZIP CODE

32. DENTIST PHONE NO.

( )
33.	34.	35a	35b	35c
No
Yes
No	Yes	HOW MANY?
No
Yes
MM
DD
CC/YY
NUMBER
▷
▷
IS TREATMENT RESULT OF

OCCUPATIONAL ILLNESS INJURY?	RADIOGRAPHS OR MODELS

ENCLOSED?	IS TREATMENT RELATED

TO ORTHODONTICS?	IS SERVICE ALREADY COMMENCED,

DATE APPLIANCES PLACED	OF ACTIVE MONTHS

OF TREATMENT
CAREFULLY FORM CHARACTERS AS SHOWN	A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0 1 2 3 4 5 6 7 8 9
TOOTH NUMBER

SURFACE	DATE SERVICE PERFORMED

PROCEDURE NUMBER	FEE
OR LETTER
MM	DD	YY
$	DOLLARS	CENTS
DO NOT TYPE IN SHADED AREA
REMARKS
I HEREBY CERTIFY THAT I HAVE PERFORMED THE PRODECURES AS INDICATED BY DATE AND / OR WISH TO PREDETERMINE THE PROCEDURES WHICH ARE NOT DATED AND THE PROCEDURES

WERE / ARE NECESSARY IN MY PROFESSIONAL JUDGEMENT.

$
SIGNED (DENTIST)	DATE
TOTAL FEE CHARGED
241-02 (7-00)	COPYRIGHTED 1999

Delta Dental	Delta Dental

Subscribers	Dental Offices

1-800-264-2818	1-800-264-2818

www.deltadental.com	www.deltadentalmi.com

INSTRUCTIONS FOR COMPLETING THE SCANNABLE CLAIM FORM

Please use this claim form for employees of Sandia National Laboratories.

FOR THIS CLAIM TO BE OPTICALLY SCANNED:

All of the information above the service area of the claim form must be clearly typed, handwritten or computer printed. If computer printed, be sure that the type alignment is correct.

All upper case letters are preferred.

Write characters as shown on the chart on the claim form, placing characters between the separator marks.

Use a black or blue ballpoint pen or felt tip pen. DO NOT USE RED OR GREEN INK.

Keep all information within the numbered boxes and within the correct fields.

Make sure typewriter and printer ribbons are dark and the print can be easily read.

Mistakes should be covered with line tape and printed or typed over. Do not use white-out or highlighter.

If you staple anything to the form, do so only at the lower front edge of the form.

PATIENT AND SUBSCRIBER INFORMATION:

For patient and subscriber information (boxes 1 and 9), enter the first name, last name and middle initial in that order. Don’t use titles such as ‘Mr.’ Or ‘Ms.’

When services are rendered by nonparticipating dentists, payment is issued to the subscriber. If benefits are to be assigned, complete box 8a. Box 8a is applicable only in cases where the patient:

Is treated by a provider outside the state of the group’s contract, or

Is enrolled in DeltaUSA and the provider is nonparticipating in one of the states listed below. (This list is subject to change.)

Alaska Florida Idaho Louisiana Montana Oregon Utah

Alabama Georgia Indiana Mississippi Nevada Texas Washington

The subscriber’s signature, box 11, is needed only when the subscriber is assigning benefits (if allowed per above). Make sure the signature fits entirely within the box.

In cases where there is another carrier involved, complete the coordination of benefits section, boxes 14-24. If no, leave these boxes empty. Don’t use zeroes, lines or N/A for not applicable. Box 18, amount of primary payment, should be filled in only when you know how much the primary carrier paid. Do not put $0 unless the primary carrier’s actual payment determination was $0. Do NOT attach the primary voucher.

PROVIDER INFORMATION:

Enter the provider name or business name in Box 25. It must exactly match the business name that is on file with Delta Dental.

Include the provider Tax Identification Number (box 26) and the license number of the treating dentist (box 28) on all claims.

Complete boxes 35b and 35c, orthodontics, only if treatment is related to orthodontics. Otherwise, leave them blank. Do not enter zeroes, lines or N/A for not applicable.

SERVICE SECTION (bottom portion):

This section can be hand printed or machine printed.

Machine printed information should be double spaced vertically using regular horizontal spacing as long as it is within the boxes; it is not necessary to print one character per separator.

List fees as dollars and cents with or without a decimal point. Because the scanner reads the last two digits as cents, if you list 25 for $25, the scanner will read as 25 cents. Enter 2500 for $25.

The remarks section should be used only for information pertaining to: the treatment rendered; determining primary/secondary coverage, such as for custodial information pertaining to a dependent; the diagnosis and treatment plan for orthodontics. Be sure to put all remarks in the remarks box or the information will be lost.

The dentist’s signature can be written, machine printed or stamped, but be sure that it is in dark ink and that it does not extend into the remarks section.

Notice To All Parties Completing This Form:

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty or insurance fraud.

© Copyright 2000 ( Delta Dental

Mail completed form to:

Dave Barton

2001-12-04

mcromer

Sandia National Laboratories