Dental Claim Form

Patient Name		Relationship to spouse			Sex	Patient Birthdate

			Self/Spouse/Child/Other			M/F	   Mo/Day/Year


Employee							Employee 
Name			Middle		Last			Social Security Number
								   -   -    

								Work Number
								(   )
Employee Mailing Address					Home Number
								(   )

City		State		Zip

Does Patient have 			If yes- Identify other coverage
Other dental Coverage?		Y  N 	______________________________

Enter the Taxpayer identifying Number
To be used for 1099 Reporting Purposes	______________________________________

Enter Exact name Associated
With taxpayer ID above			______________________________________

Enter Dentist License Number
Associated with taxpayer ID above	______________________________________

Mailing Address		_________________   	Please issue Payment Directly to the Dentist
						_________________________________
						_________________________________

						Signed (covered Employee)

Radio Graphs Enclosed-	Yes_No_F.M.S_Panorex_Bitewing_How many?_Periapicals_How Many?_

Employee Signature	_____________		Dentist Signature	________________

	Date		_____________		Date			________________