This Claim is for: Self Child Spouse

Patient’s Last Name Patient’s First Name Male Female

Date of Birth (mm/dd/yyyy)

Social Security Number Last Name First Name Mid . Initial

Mailing Address Street:

City State ZIP code Date of Birth (mm/dd/yyyy)

Home phone ( ) Work phone ( ) Email Address

Employer Employer’s Address Street:

City State ZIP C ode

Is the patient covered under another orthodontic plan Yes No

If “Yes,” you must provide the information below.

Other Plan’s phone( )

Other Plan’s Mailing Address Street:

City State ZIP c ode

Request For Authorization AndBenefits For Orthodontic Treatment

PARTICIPANT INFORMATION Supply all information requested below.

SPOUSE/DOMESTIC PARTNER’S INFORMATION Supply all information requested below.

Social Security Number Last Name First Name Mid . Initial

M

( )

Name of Other Plan Name of Primary Insured

United Food & Commercial Workers Unions and Food Employers Benefit Fund6425 Katella Avenue, Cypress, CA 90630-5238

P.O. Box 6010, Cypress, CA 90630-0010

714-220-2297 • 562-408-2715 • 877-284-2320

www.scufcwfunds.com

I hereby certify the statements hereon and those attached are true and correct to the best of my knowledge and I authorize any physician, surgeon, practitioner or other person, anyhospital, including veterans administration or governmental hospital, any medical service organization, any insurance company, or other institution or organization, to release to eachother any medical or other information acquired, including benefits paid or payable, concerning this or other disabilities. A photostat of this authorization shall be as valid as the original.I understand that it is fraudulent to fill out this form with information I know to be false or to omit important facts, and that criminal and/or civil penalties can result from such acts.

______________________________________________________________________ ______________________________________________________________________Participant’s Signature Date Spouse/Domestic Date

Partner’s SignatureI hereby authorize payments directly to the provider named below for services of the benefits otherwise payable to me under the terms and conditions of the Benefit Fund. I understandI am financially responsible to the provider for charges not covered by the Fund.

______________________________________________________________________ ______________________________________________________________________Participant’s Signature Date Spouse/Domestic Date

Partner’s Signature

Orthodontic Treatment And Charges To be Completed By Orthodontist. Prior Approval Required On All Treatment Plans.

1. Date of first visit (current series)_______________________ Date of Appliance Placement______________________2. Phase: ☐ Full ☐ Phase I ☐ Phase II3. Diagnosis, Treatment Mechanics and treatment plan (to include type of appliance and retainers.) Attach additional sheet if necessary.

M

( ) ( )

E

)

ORTHODONTIST INFORMATION Supply all information requested below.

Tax I.D. Number Corporation Name Orthodontist’s Name

Mailing Address Street:

City State ZIP c ode Office phone ( )

Orthodontist’s Signature Date

WHITE & YELLOW - Fund Office PINK - Orthodontist FM CL BR01 0411

4. SET OF INTRAORAL PHOTOGRAPHS AND X-RAYS MUST ACCOMPANY CLAIM FORM.5. Cost of Diagnostic Records, Date of Service:___________________ Charges: $_________________

Study Models and X-Rays (ADA Code 08999)6. Total orthodontic fee, exclusive of case analysis: Charges: $_________________7. Are you an Orthodontic Specialist? ☐ Yes ☐ No Member of______________________________Orthodontic Society