1. Patient’s Full Name (First, Middle Initial, Last)
2. Relationship to Employee
3. Sex
4. Patient Birthdate
Self
Spouse
Child
Other
F
Mo.
Day
Year
5. Employee’s Full Name (First, Middle Initial, Last)
Employee’s Birthdate
6. Employee’s Social Security Number
Mo.
Day
Year
7. Employee’s Mailing Address (Street, City, Zip)
Street or P. O. Box
City, State, Zip
8. THIS SECTION MUST BE COMPLETED WITH EACH CLAIM SUBMISSION ONLY IF THE
CLAIM IS FOR A DEPENDENT CHILD AGE 19 OR OVER.
Is patient a full time student? Yes No
If yes, Name of School
Address of School
9. Employee’s Company Name and Address
10. Group No.
Div. No.
Cert. No.
QUESTION 11. MUST BE COMPLETED WITH EACH CLAIM SUBMISSION
11. Is patient covered by another dental plan? Yes No If yes, Employer/Plan Name____________________________Policy Number
Name and Address of Insurance Carrier
If yes, please complete below:
Name of Insured:
Relationship
Date of Birth
Social Security Number
Name and Address of Employer:
Spouse
Child
Mo.
Day
Year
I have reviewed the treatment plan, and I authorize release of any information relating to
this claim. I understand I am responsible for all cost of dental treatment. I certify these
statements to be true and complete to the best of my knowledge. I understand that any
person who knowingly and with intent to injure, defraud or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading
information is guilty of a felony. All work covered on this form has been completed.
____________________________________________ _____/_____/_____
Signed (Patient, or parent if minor) Date
I hereby authorize payment direct to the below named dentist of the group
insurance benefits otherwise payable to me.
____________________________________________ _____/_____/_____
Signed (Insured Person) (If signed here, signature also needed in box on left.) Date
PART 2 – TO BE COMPLETED BY ATTENDING DENTIST – Please provide ADA Procedure Number to ensure accurate benefit determination.
Name of Patient: DENTIST – CHECK ONE:
Pretreatment Estimate
Statement of Actual Services
Name of Insured Person: Has all work been completed? Y____N____
12. Dentist Name and 13. Mailing Address
20. Is treatment result of
occupational illness or injury?
No
Yes
If yes, enter brief description and dates.
21. Is treatment result of Auto
Accident?
22. Other Accident?
23. Are any services covered by
another plan?
14. Dentist Soc. Sec. Or TIN
15. Dentist License
#
16. Dentist Phone
#
24. If Prosthesis, is this initial
placement?
(If no, reason for replacement) Date of
prior placement
17. First Visit
Date Current
Series
18. Place of Treatment
19. Radiographs or
Models enclosed?
No
Yes
How
Many?
25. Is treatment for
Orthodontics?
Enter date appliances placed, if
services already commenced.
____/____/____
Months of treatment remaining:_______
Office
Hosp
Identify Missing Teeth with “X”
Remarks for unusual services.
Tooth No.
or Letter
Surfaces
DESCRIPTION OF SERVICES
(including X-rays, Prophylaxis, Materials used, etc.)
ADA Procedure
Number
Date Service Performed
Mo. Day Yr.
Fee
$
CERTIFICATION: I certify that the services listed above have been completed on the dates indicated and that the fees
submitted are the fees I have charged and intend to collect for those purposes.
TOTAL FEE CHARGED
$
__________________________________________ _____/_____/_____
SIGNED (DENTIST) DATE
GROUP DENTAL CLAIM FORM
PART 1 – TO BE COMPLETED BY EMPLOYEE
Group Claim Office
P. O. Box 80139, Baton Rouge, LA 70898-0139
Toll Free No.: 1-888-729-5433 (B.R. 926-2888)
Clear Form
Tips to Speed Claims
Processing
Part 1 – Employee
Missing or incomplete responses on claim forms cause delays in processing a claim. The items most frequently left out are:
#4 Date of Birth: Helps identify an insured and determine dependent eligibility.
#6 Social Security Number: This is the most important identifier for the plan member.
#8 Student Status: Required on every claim for a dependent age 19 years and older as student status is subject to change
since the last claim was processed.
#11 Coordination of Benefits: The “No” box in Question 11 should be checked if no other DENTAL coverage exists. If
there is other DENTAL coverage, the additional information requested is necessary for coordination of benefits as required
by most group insurance plans. This information is required on every claim as it is subject to change since the last claim was
processed.
Signatures: There are two signature lines on the claim form. The left signature line is for the patient to sign which
authorizes release of information by the dentist relative to the immediate claim. This signature line must always be signed.
The right signature line should be signed by the plan member if you want Starmount to pay your dentist. If not, this line
should be left blank.
Part 2 – Information Provided by Dentist
Films and Charting: Certain procedures are reviewed by our Dental Consultants. Include films with surgical extractions,
crowns, inlays, and bridges. Duplicate films should be labeled left and right. All films should be dated. Periodontal charting
and/or films are required for all reported periodontal procedures.
If diagnostic films and charts are unavailable, a narrative should be included on, or attached to, the claim.
Prosthesis-Initial or Replacement: Required for crowns, inlays/onlays, bridges, and partial or complete dentures. If
prosthesis is a replacement, the prior placement date is needed.
Pretreatment Estimate Or Actual Services: Appropriate box should be marked to ensure correct handling.
Tooth Number or Letters: Site-specific information is required to process claim. This also includes the listing of the
specific quadrant or arch, and tooth number in accordance to the ADA coding.
Pretreatment Estimate of Benefits
A Pretreatment Estimate of Benefits lets you know in advance what your benefits will be. Before signing a course of
treatment, have your dentist estimate the charges and submit for a pretreatment estimate. This will eliminate
misunderstanding and let both you and your dentist know what the plan will pay. If your dental coverage terminates for any
reason during treatment, only the procedures performed before the dental coverage terminated will be eligible for payment.
You should review your booklet for full information regarding your coverage.
We recommend a pretreatment estimate if your dental work will cost $300 or more.