ATTENDING DENTIST’S STATEMENT

Check one: Dentist’s pre-treatment estimate Dentist’s statement of actual services

Carrier name and address: Horizon Blue Cross Blue Shield of New Jersey Dental Programs PO Box 1311 Minneapolis, MN 55440-1311

PATIENTCOVERAGEINFORMATION

1. Patient name first m.i. last

2. Relationship to employee self child spouse other ___________

3. Sex M F

4. Patient birth date MM DD YYYY

5. Full time student yes no If yes: School City

6. Employee/subscriber name & mailing address 7. Employee/subscriber soc sec or I.D. number

8. Employee/subscriberbirth date

MM DD YYYY

9. Employer (company) name and address 10. Group number

11. Is patient covered by another dental plan? yes no If yes, complete 12-a

Is patient covered by a medical plan? yes no

12-a. Name and address of carrier(s) 12-b. Group No.(s) 13. Name and address of other employer(s)

14-a. Employee/subscriber name (if different than patient’s) 14-b. Employee/subscriber soc. sec. or I.D. number

14 c. Employee/subscriber birth date MM DD YYYY

15. Relationship to patient self parent

spouse other I have reviewed the following treatment plan. I authorize release of any information relating to this claim. I understand that I am responsible for all costs of dental treatment.

►____________________________________________________________________________Signed (insured person) Date

I hereby authorize payment of the dental benefits otherwise payable to me directly to the below named dental entity.

►_____________________________________________________ __________________Signed (insured person) Date

BILLING

DENTIST

16. Name of Billing Dentist or Dent tluser tnemtaert sI .42ytitnE laof occupational illness or injury?

No Yes If yes, enter brief description and dates

17. Address where payment should be remitted 25. Is treatment result of auto accident?

?tnedicca rehtO .62 piZ ,etatS ,ytiC

18. Dentist Soc Sec or T.I.N. 19. Dentist license no. 20. Dentist phone no. 27. If prosthesis, is thisinitial placement?

If no, reason for replacement 28. Date of priorplacement

21. First visit datecurrent series

22. Place of treatment Office Hosp ECF Other

23. Radiographsor modelsenclosed

No Yes How many?

29. Is treatment fororthodontics?

If services already Date appliance Mos. treatment commenced placed: remaining: enter:

Identify missing teeth with ‘x’ 30. Examination and treatment plan – List in order from tooth no. 1 through tooth no. 32 – Use charting system shown. Tooth # or letter

Surface Description of service (including x-rays, prophylaxis, materials used, etc.)

Date service Performed

Mo. Day Year

Procedure Number

Fee For administrative use only

31. Remarks for unusual services

I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures.

►________________________________________________________________________________________________ Signed (Treating Dentist) License Number NPI Date

Total fee charged

Max. allowable Customer service phone number – 1 (800) 4 DENTAL Deductible

Carrier % Carrier pays Patient Pays

7902 (W0113)

Carrier name and address: 1 Pat ent name first mi last: onship to employee: 6 Employeesubscriber name mailing address: 7 Employeesubscriber soc sec or ID number: 9 Employer company name and address: 10 Group number: 12a Name and address of carriers: 12b Group Nos: 13 Name and address of other employers: 14a Employeesubscriber name if different than patients: 14b Employeesubscriber soc sec or ID number: Date: Date_2: 17 Address where payment should be remitted: If yes enter brief descript on and dates25 Is treatment result of auto accident: C ty State Zip: If yes enter brief descript on and dates26 Other accident: 18 Dentist Soc Sec or TIN: 19 Dentist license no: 20 Dentist phone no: If no reason for replacement: 28 Date of prior placement: 21 First visit date current series: Tooth or letterRow1: SurfaceRow1: Descript on of service including xrays prophylaxis materials used etcRow1: Date service Performed Mo Day YearRow1: Date service Performed Mo Day YearRow1_2: Date service Performed Mo Day YearRow1_3: Procedure NumberRow1: Procedure NumberRow1_2: FeeRow1: FeeRow1_2: Tooth or letterRow2: SurfaceRow2: Descript on of service including xrays prophylaxis materials used etcRow2: Date service Performed Mo Day YearRow2: Date service Performed Mo Day YearRow2_2: Date service Performed Mo Day YearRow2_3: Procedure NumberRow2: Procedure NumberRow2_2: FeeRow2: FeeRow2_2: Tooth or letterRow3: SurfaceRow3: Descript on of service including xrays prophylaxis materials used etcRow3: Date service Performed Mo Day YearRow3: Date service Performed Mo Day YearRow3_2: Date service Performed Mo Day YearRow3_3: Procedure NumberRow3: Procedure NumberRow3_2: FeeRow3: FeeRow3_2: Tooth or letterRow4: SurfaceRow4: Descript on of service including xrays prophylaxis materials used etcRow4: Date service Performed Mo Day YearRow4: Date service Performed Mo Day YearRow4_2: Date service Performed Mo Day YearRow4_3: Procedure NumberRow4: Procedure NumberRow4_2: FeeRow4: FeeRow4_2: Tooth or letterRow5: SurfaceRow5: Descript on of service including xrays prophylaxis materials used etcRow5: Date service Performed Mo Day YearRow5: Date service Performed Mo Day YearRow5_2: Date service Performed Mo Day YearRow5_3: Procedure NumberRow5: Procedure NumberRow5_2: FeeRow5: FeeRow5_2: Tooth or letterRow6: SurfaceRow6: Descript on of service including xrays prophylaxis materials used etcRow6: Date service Performed Mo Day YearRow6: Date service Performed Mo Day YearRow6_2: Date service Performed Mo Day YearRow6_3: Procedure NumberRow6: Procedure NumberRow6_2: FeeRow6: FeeRow6_2: Tooth or letterRow7: SurfaceRow7: Descript on of service including xrays prophylaxis materials used etcRow7: Date service Performed Mo Day YearRow7: Date service Performed Mo Day YearRow7_2: Date service Performed Mo Day YearRow7_3: Procedure NumberRow7: Procedure NumberRow7_2: FeeRow7: FeeRow7_2: Tooth or letterRow8: SurfaceRow8: Descript on of service including xrays prophylaxis materials used etcRow8: Date service Performed Mo Day YearRow8: Date service Performed Mo Day YearRow8_2: Date service Performed Mo Day YearRow8_3: Procedure NumberRow8: Procedure NumberRow8_2: FeeRow8: FeeRow8_2: Tooth or letterRow9: SurfaceRow9: Descript on of service including xrays prophylaxis materials used etcRow9: Date service Performed Mo Day YearRow9: Date service Performed Mo Day YearRow9_2: Date service Performed Mo Day YearRow9_3: Procedure NumberRow9: Procedure NumberRow9_2: FeeRow9: FeeRow9_2: Tooth or letterRow10: SurfaceRow10: Descript on of service including xrays prophylaxis materials used etcRow10: Date service Performed Mo Day YearRow10: Date service Performed Mo Day YearRow10_2: Date service Performed Mo Day YearRow10_3: Procedure NumberRow10: Procedure NumberRow10_2: FeeRow10: FeeRow10_2: Tooth or letterRow11: SurfaceRow11: Descript on of service including xrays prophylaxis materials used etcRow11: Date service Performed Mo Day YearRow11: Date service Performed Mo Day YearRow11_2: Date service Performed Mo Day YearRow11_3: Procedure NumberRow11: Procedure NumberRow11_2: FeeRow11: FeeRow11_2: Tooth or letterRow12: SurfaceRow12: Descript on of service including xrays prophylaxis materials used etcRow12: Date service Performed Mo Day YearRow12: Date service Performed Mo Day YearRow12_2: Date service Performed Mo Day YearRow12_3: Procedure NumberRow12: Procedure NumberRow12_2: FeeRow12: FeeRow12_2: Tooth or letterRow13: SurfaceRow13: Descript on of service including xrays prophylaxis materials used etcRow13: Date service Performed Mo Day YearRow13: Date service Performed Mo Day YearRow13_2: Date service Performed Mo Day YearRow13_3: Procedure NumberRow13: Procedure NumberRow13_2: FeeRow13: FeeRow13_2: Tooth or letterRow14: SurfaceRow14: Descript on of service including xrays prophylaxis materials used etcRow14: Date service Performed Mo Day YearRow14: Date service Performed Mo Day YearRow14_2: Date service Performed Mo Day YearRow14_3: Procedure NumberRow14: Procedure NumberRow14_2: FeeRow14: FeeRow14_2: Tooth or letterRow15: SurfaceRow15: Descript on of service including xrays prophylaxis materials used etcRow15: Date service Performed Mo Day YearRow15: Date service Performed Mo Day YearRow15_2: Date service Performed Mo Day YearRow15_3: Procedure NumberRow15: Procedure NumberRow15_2: FeeRow15: FeeRow15_2: Fee31 Remarks for unusual services: Fee31 Remarks for unusual services_2: Fee31 Remarks for unusual services_3: Fee31 Remarks for unusual services_4: Fee31 Remarks for unusual services_5: Fee31 Remarks for unusual services_6: License Number: NPI: Date_3: Total fee charged: For administrative use only: Max allowable: Deduct ble: Carrier: Carrier pays: Patient Pays: Check Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: Offyyyy: school: mm: dd: Check Box5: Off2mm: 2dd: 2yyyy: 3mm: 3dd: 3yyyy: Check Box6: Off16 Name of Billing Dentist or Dental Entity: if yes: Check Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffHow many: date: treatment: Remarks: city: Reset: