EMPLOYEE AND PATIENT PORTION EMPLOYEES CONTRACT NUMBERSSN EMPLOYEE FIRST LAST NAME DATE OF BIRTH EMPLOYEES ADDRESS PATIENT NAME ID: 895870
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1 DENTAL CLAIM FORM FOR USE IF DENTAL
DENTAL CLAIM FORM FOR USE IF DENTAL PROVIDER WILL NOT Eligibility Verification 1-888-236-1100 SUBMIT CLAIM ON PATIENT BEHALF MAIL CLAIM FORM TO: ADN PO BOX 610 SOUTHFIELD, MI 48037 Fax: 248-901-3711 Employer ______________________________________________ EMPLOYEE AND PATIENT PORTION EMPLOYEES CONTRACT NUMBER/SSN EMPLOYEE FIRST & LAST NAME DATE OF BIRTH EMPLOYEES ADDRESS PATIENT NAME PATIENTS RELATIONSHIP TO EMPLOYEE SELF SPOUSE CHILD OTHER OTHER INSURANCE COVERAGE IS PATIENT COVERED BY ANOTHER VISION PLAN? YES NO IF YES, PROVIDE NAME AND ADDRESS OF CARRIER SOCIAL SECURITY NUMBER OF OTHER INSURED NAME OF EMPLOYER OTHER INSUREDS NAME DATE OF BIRTH IS THIS CONDITION CAUSED BY EMPLOYMENT? EXPLAIN DOES CLAIM INVOLVE INJURY? YES NO WAS PATIENT INJURED AT WORK? YES NO DATE AND TIME OF INJURY___________________________________________ I AUTHORIZE THE UNDERSIGNED PHYSICIAN TO RELEASE I AUTHORIZE PAYMENT OF BENEFITS TO UNDERSIGNED ANY INFORMATION ACQUIRED DURING MY EXAM OR TREATMENT. PHYSICIAN OR SUPPLIER OF SERVICES DESCRIBED BELOW. DO NOT SIGN IF YOU HAVE PAID UP FRONT FOR SERVICES ___________________________________________________________________________________________________________________________________________________ SIGNED (EMPLOYEE OR PATIENT) DATE SIGNED (EMPLOYEE OR PATIENT) DATE TO BE COMPLETED BY SERVICE PROVIDER OR ATTACH A DETAILED RECEIPT OR CLAIM DATE(S) OF SERVICE PROCEDURE CODE DESCRIPTION DIAGNOSIS CHARGE BILLING ENTITY AND ADDRESS TAX ID NUMBER - PHYSICIANS LICENSE NUMBER - ________________________________________________ SIGNATURE OF TREATING PHYSICIAN DATE PHONE NUMBER - DENTAL CLAIM FORM FOR USE IF DENTAL PROVIDER WILL NOT Eligibility Verification 1-888-236-1100 SUBMIT CLAIM ON PATIENT BEHALF MAIL CLAIM FORM TO: ADN PO BOX 610 SOUTHFIELD, MI 48037 Fax: 248-901-3711 Employer _ EMPLOYEE AND PATIENT PORTION EMPLOYEE’S CONTRACT NUMBER/SSN EMPLOYEE FIRST & LAST NAME DATE OF BIRTH EMPLOYEE’S ADDRESS PATIENT NAME PATIENT’S RELATIONSHIP TO EMPLOYEE SELF SPOUSE CHILD OTHER OTHER INSURANCE COVERAGE IS PATIENT COVERED BY ANOTHER VISION PLAN? YES NO IF YES, PROVIDE NAME AND ADDRESS OF CARRIER SOCIAL SECURITY NUMBER OF OTHER INSURED NAME OF EMPLOYER OTHER INSURED’S NAME DATE OF BIRTH IS THIS CONDITION CAUSED BY EMPLOYMENT? EXPLAIN DOES CLAIM INVOLVE INJURY? YES NO WAS PATIENT INJURED AT WORK? YES NO DATE AND TIME OF INJURY___________________________________________ I AUTHORIZE THE UNDERSIGNED PHYSICIAN TO RELEASE I AUTHORIZE PAYMENT OF BENEFITS TO UNDERSIGNED ANY INFORMATION ACQUIRED DURING MY EXAM OR TREATMENT. PHYSICIAN OR SUPPLIER OF SERVICES DESCRIBED BELOW. DO NOT SIGN IF YOU HAVE PAID UP FRONT FOR SERVICES __________________________________________________________________________________________________________________________________________________ SIGNED (EMPLOYEE OR PATIENT) DATE SIGNED (EMPLOYEE OR PATIENT) DATE TO BE COMPLETED BY SERVICE PROVIDER OR ATTACH A DETAILED RECEIPT OR CLAIM DATE(S) OF SERVICE PROCEDURE CODE DESCRIPTION DIAGNOSIS CHARGE BILLING ENTITY AND ADDRESSTAX ID NUMBER - PHYSICIAN’S LICENSE NUMBER - _______________________________________________ SIGNATURE OF TREATING PHYSICIAN DATE PHONE NUMBER -