GHI Dental Claim Form

Part A Subscriber Information

Subscriber's Certificate Number		Catergory 	Group

Subscriber's Name and Address
Last		First


Address

City		State	Zip Code

Area Code	Telephone Number
(   )			-


Part B Patient Information

Patient Name and Address		Birthdate		Sex
Last		First			mm/dd/year		M/F


Address

City		State	Zip Code

Area Code	Telephone Number
(   )			-

Is Patient Disabled								Y/N

Is Patient a dependent student age 19 or over?  				Y/N

Was condition related to Patients Employment?					Y/N

Was condition related to an Auto Accident?					Y/N

Was condition related to an other Accident?					Y/N


Dentist information

Dentist Name and Address		
Last		First			


Address

City		State	Zip Code

Area Code	Telephone Number
(   )			-

Dentist Tax identification Number 

Dentist License Number

Specialty