Form GC-14423 "Dentist's Statement - Aetna" - Florida

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Download Form GC-14423 "Dentist's Statement - Aetna" - Florida

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Aetna Global Benefits
Dentist's Statement
®
Coverage underwritten by Aetna Life Insurance Company
and Aetna Life & Casualty (Bermuda) Ltd.
! This form should be completed and submitted if an itemized bill is
! If this is for a pre-treatment estimate, leave the date blank for those
services that have not been completed. Our estimate and your X-rays will
not provided to accompany the Claim Form (GR-68069) and/or if
be returned to you promptly. Estimates are subject to deductible and plan
treatment is for other than an examination, cleaning or x-rays. The
maximums and may be reduced by payments made before these
Summary of Reimbursement section of the Dental Benefit Request
services are rendered. The estimate is based on the assumption the
form will identify the party to whom benefit payments should be
patient will receive the services while covered and the treatment plan
made payable/sent.
does not change. Actual payment may differ from the estimate.
! Fully itemized bills and receipts should include: Patient's name and
relationship to employee, Provider Name/address/telephone number,
Indicate date of treatment only when treatment has been completed.
condition being treated, date of service, type of service rendered and the
Describe any changes in the treatment plan.
tooth or teeth affected by treatment, amount charged, and procedures
! Submit X-rays with:
performed. If this information is not shown, you may hand-write it on the
-
request for pre-treatment estimates
bill/receipt and sign your name.
-
treatments involving gold restorations, crowns, implants or
! If fully itemized bills are not provided or if services rendered are for other
bridgework.
than examinations, cleanings or x-rays, Provider's should complete this
! X-rays may be requested for other service.
form and attach it to all bills and a completed Claim Form (GR-68069),
! Identify any missing teeth and date extracted on the tooth chart below.
and mail them to the address on the back of the member's insurance
Identification Card or Aetna Global Benefits, P.O. Box 30258,
Tampa, FL 33630-3258, U.S.A.
1. Employee's Name
2. Employee's Social Security/I.D. Number
3. Patient's Name
4. Patient's Birthdate (mm/dd/yyyy)
5. This is a
Request for pre-treatment estimate
Statement of services rendered
6. Dentist's Name & Address (include zip code)
7. Telephone No.
8. Dentist License No.
(
)
9. If applicable, enter the taxpayer identifying number to be used for U.S. 1099 reporting purposes.
You are required under authority of U.S. law to furnish your taxpayer identifying number.
10. First Visit Date Current
11. Place of Treatment
12. Radiographs or models
Series
Office
Hosp.
enclosed?
No
Yes
ECF
Other
How many?
Is treatment result of:
No
Yes
If yes, enter brief description and dates
13.
occupational illness or injury?
14.
auto accident?
15.
other accident?
16. Are any services covered by another plan?
17. If prosthesis, is this initial placement?
If no, date of prior placement and reason for replacement
18. Is treatment for orthodontics?
Date appliance placed:
Initial Appliance Fee:
No. of months of treatment:
Monthly Fee:
Mos. of treatment remaining:
Total Case Fee:
19. To expedite claim handling,
20. Examination and treatment plan. List in order from tooth no. 1 through tooth no. 32.
Use charting system shown.
identify all missing teeth with "X"
Tooth #
If Previously
Surface
Description of Service (x-rays,
Date Service
Procedure
Fee
or
Extracted,
prophylaxis, materials used, etc.)
Performed
Number
Letter
Give Date
(mm/dd/yyyy)
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
21. I hereby certify that the procedures as indicated by date have been completed and that the fees submitted
Total charge $
are the actual fees I have charged this patient and intend to accept for those procedures.
Amount paid $
Dentist's Signature
Date
Balance due $
Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to claim was provided by the applicant.
California Residents: For your protection, California law requires notice of the following: Any person who knowingly and with intent to defraud or deceive any
insurance company files a statement of claim containing any materially false, incomplete or misleading information is guilty of a crime and may be subject to
fines, confinement in a state prison and substantial civil penalties.
Colorado Residents: An insurer or agent who knowingly provides false or misleading information to defraud a claimant regarding insurance
proceeds must be reported to the Insurance Division.
Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Please Retain A Copy For Your Records
GC-14423 (11-04) A-POD
Aetna Global Benefits
Dentist's Statement
®
Coverage underwritten by Aetna Life Insurance Company
and Aetna Life & Casualty (Bermuda) Ltd.
! This form should be completed and submitted if an itemized bill is
! If this is for a pre-treatment estimate, leave the date blank for those
services that have not been completed. Our estimate and your X-rays will
not provided to accompany the Claim Form (GR-68069) and/or if
be returned to you promptly. Estimates are subject to deductible and plan
treatment is for other than an examination, cleaning or x-rays. The
maximums and may be reduced by payments made before these
Summary of Reimbursement section of the Dental Benefit Request
services are rendered. The estimate is based on the assumption the
form will identify the party to whom benefit payments should be
patient will receive the services while covered and the treatment plan
made payable/sent.
does not change. Actual payment may differ from the estimate.
! Fully itemized bills and receipts should include: Patient's name and
relationship to employee, Provider Name/address/telephone number,
Indicate date of treatment only when treatment has been completed.
condition being treated, date of service, type of service rendered and the
Describe any changes in the treatment plan.
tooth or teeth affected by treatment, amount charged, and procedures
! Submit X-rays with:
performed. If this information is not shown, you may hand-write it on the
-
request for pre-treatment estimates
bill/receipt and sign your name.
-
treatments involving gold restorations, crowns, implants or
! If fully itemized bills are not provided or if services rendered are for other
bridgework.
than examinations, cleanings or x-rays, Provider's should complete this
! X-rays may be requested for other service.
form and attach it to all bills and a completed Claim Form (GR-68069),
! Identify any missing teeth and date extracted on the tooth chart below.
and mail them to the address on the back of the member's insurance
Identification Card or Aetna Global Benefits, P.O. Box 30258,
Tampa, FL 33630-3258, U.S.A.
1. Employee's Name
2. Employee's Social Security/I.D. Number
3. Patient's Name
4. Patient's Birthdate (mm/dd/yyyy)
5. This is a
Request for pre-treatment estimate
Statement of services rendered
6. Dentist's Name & Address (include zip code)
7. Telephone No.
8. Dentist License No.
(
)
9. If applicable, enter the taxpayer identifying number to be used for U.S. 1099 reporting purposes.
You are required under authority of U.S. law to furnish your taxpayer identifying number.
10. First Visit Date Current
11. Place of Treatment
12. Radiographs or models
Series
Office
Hosp.
enclosed?
No
Yes
ECF
Other
How many?
Is treatment result of:
No
Yes
If yes, enter brief description and dates
13.
occupational illness or injury?
14.
auto accident?
15.
other accident?
16. Are any services covered by another plan?
17. If prosthesis, is this initial placement?
If no, date of prior placement and reason for replacement
18. Is treatment for orthodontics?
Date appliance placed:
Initial Appliance Fee:
No. of months of treatment:
Monthly Fee:
Mos. of treatment remaining:
Total Case Fee:
19. To expedite claim handling,
20. Examination and treatment plan. List in order from tooth no. 1 through tooth no. 32.
Use charting system shown.
identify all missing teeth with "X"
Tooth #
If Previously
Surface
Description of Service (x-rays,
Date Service
Procedure
Fee
or
Extracted,
prophylaxis, materials used, etc.)
Performed
Number
Letter
Give Date
(mm/dd/yyyy)
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
21. I hereby certify that the procedures as indicated by date have been completed and that the fees submitted
Total charge $
are the actual fees I have charged this patient and intend to accept for those procedures.
Amount paid $
Dentist's Signature
Date
Balance due $
Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to claim was provided by the applicant.
California Residents: For your protection, California law requires notice of the following: Any person who knowingly and with intent to defraud or deceive any
insurance company files a statement of claim containing any materially false, incomplete or misleading information is guilty of a crime and may be subject to
fines, confinement in a state prison and substantial civil penalties.
Colorado Residents: An insurer or agent who knowingly provides false or misleading information to defraud a claimant regarding insurance
proceeds must be reported to the Insurance Division.
Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Please Retain A Copy For Your Records
GC-14423 (11-04) A-POD