4521 (9/17)

HEADER INFORMATION1. Type of Transaction (Check all applicable boxes)

� Statement of Actual Services – OR – � Request for Predetermination/Preauthorization

CARRIER NAME AND ADDRESS:2. Delta Dental of Illinois

P.O. Box 5402Lisle, IL 60532

(Please do not use for DeltaCare dental HMO)PRIMARY PAYER INFORMATION3. Name, Address, City, State, Zip Code

PRIMARY SUBSCRIBER INFORMATION4. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

5. Date of Birth (MM/DD/CCYY) 6. Gender 7. Subscriber Identifier (SSN or ID#)� M � F

8. Plan/Group Number 9. Employer Name

PATIENT INFORMATION10. Relationship to Primary Subscriber (Check applicable box) 11. Student Status

� Self � Spouse � Dependent Child � Other � FTS � PTS

12. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

13. Date of Birth (MM/DD/CCYY) 14. Gender 15. Patient ID/Account # (Assigned by Dentist)� M � F

OTHER COVERAGE

16. Other Dental or Medical Coverage? � No (Skip 17-23) � Yes (Complete 16-23)

17. Subscriber Name (Last, First, Middle Initial, Suffix)

18. Date of Birth (MM/DD/CCYY) 19. Gender 20. Subscriber Identifier (SSN or ID#)� M � F

21. Plan/Group Number 22. Relationship to Primary Subscriber (Check applicable box)� Self � Spouse � Dependent � Other

23. Other Carrier Name, Address, City, State, Zip Code

RECORD OF SERVICES PROVIDED24. Procedure Date 25. Area 26. 27. Tooth Number(s) 28. Tooth 29. Procedure 29a. Diag. Pointer

(MM/DD/CCYY) of Oral Tooth or Letter(s) Surface Code 30. Description 31. FeeCavity System

1

2

3

4

5

6

7

8

9

10

MISSING TEETH INFORMATION Permanent Primary33. (Place an ‘X’ on each missing tooth) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I J

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T S R Q P O N M L K

31a. OtherFee(s)

32. Total Fee

35. Remarks

AUTHORIZATIONS36. I have been informed of the treatment plan and associated fees. I agree to be responsiblefor all charges for dental services and materials not paid by my dental benefit plan, unless pro-hibited by law, or the treating dentist or dental practice has a contractual agreement with myplan prohibiting all or a portion of such charges. To the extent permitted by law, I consent toyour use and disclosure of my protected health information to carry out payment activities inconnection with this claim.X_________________________________________________________________________________________Patient/Guardian signature Date

37. I hereby authorize and direct payment of the dental benefits otherwise payable to me,directly to the below named dentist or dental entity.

X_________________________________________________________________________________________Subscriber signature Date

BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber)

48. Name, Address, City, State, Zip Code

49. Corporate Entity NPI (Type 2) 50. License Number 51. SSN or TIN

ANCILLARY CLAIM/TREATMENT INFORMATION38. Place of Treatment (Check applicable box) 39. Number of Enclosures (00 to 99)

� Provider’s Office � Hospital � ECF � OtherRadiograph(s) Oral Image(s) Model(s)

40. Is Treatment for Orthodontics? 41. Date Appliance Placed (MM/DD/CCYY)� No (Skip 41-42) � Yes (Complete 41-42)

42. Months of Treatment 43. Replacement of Prostheses? 44. Date Prior Placement (MM/DD/CCYY)Remaining � No � Yes (Complete 44)

45. Treatment Resulting from (Check applicable box)� Occupational illness/injury � Auto accident � Other accident

46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State

TREATING DENTIST AND TREATMENT LOCATION INFORMATION53. I hereby certify that the procedures as indicated by date are in progress (for proceduresthat require multiple visits) or have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures.

X_________________________________________________________________________________________Signed (Treating Dentist) Date

54. Individual NPI (Type 1) 55. License Number

56. Address, City, State, Zip Code 56a. Provider Specialty Code

57. Phone Number ( ) – 58. Treating ProviderSpecialty

34. Diagnosis Code List Qualifier �� (ICD-9 = B, ICD-10 = AB) 34a. Diagnosis Code(s) A _______________ B ________________ C _______________ D ________________(Primary diagnosis in “A”)

52. Phone Number ( ) – 52a. Additional Provider ID

Discrimination is Against the Law Delta Dental of Illinois complies with all applicable Federal and State civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, gender, or gender identity. Delta Dental of Illinois does not exclude people or treat them differently because of race, color, national origin, age, disability, gender or gender identity. Delta Dental of Illinois:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats,

etc.)

Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact our Civil Rights Coordinator: Stacey Bonn If you believe that Delta Dental of Illinois has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, gender, or gender identity, you can file a grievance with: Director of Client Services Delta Dental of Illinois 111 Shuman Boulevard Naperville IL 60563 Phone: 800-323-1743 Email: csi@deltadentalil.com You can file a grievance in person or by mail, phone or email. If you need help filing a grievance, our Director of Client Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://hhs.gov/ocr/office/file/index.html

mailto:csi@deltadentalil.comhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://hhs.gov/ocr/office/file/index.html

Arabic

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Chinese

繁體中文

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-323-1743。

French

Français

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le

1-800-323-1743. German

Deutsch

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.

Rufnummer: 1-800-323-1743. Greek

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δωρεάν. Καλέστε 1-800-323-1743. Gujarati

ગજુરાતી

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हिंदी

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ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il

numero 1-800-323-1743. Korean

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Polski

Polski

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Русский

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-323-1743. Spanish

Español

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-323-1743. Tagalog

Tagalog

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.

Tumawag sa 1-800-323-1743. Urdu

وارد

خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال

کريں .1-800-323-1743 Vietnamese

Tiếng Việt

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-323-1743.

.1-800-323-1743

If you or someone you are helping has questions about Delta Dental of Illinois,you have the right to get help and information in your language at no cost.

1: Check Box1: Off Check Box2: Off

3: Primary Payer Name: Primary Payer Address:

4: Primary Subscriber Name and Address:

5: DOB:

6: Check Box1: Off Check Box2: Off

7: SSN:

8: Plan No:

9: Employer Name:

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11: Check Box1: Off Check Box2: Off

12: Name and Address:

13: DOB:

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15: Patient ID:

Other Coverage: 16: Check Box1: Off Check Box2: Off

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18: DOB:

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21: Plan/Group Number:

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23: Other Carrier Name: Other Carrier Address:

24: Procedure Date1: Procedure Date2: Procedure Date3: Procedure Date4: Procedure Date5: Procedure Date6: Procedure Date7: Procedure Date8: Procedure Date9: Procedure Date10:

25: Area of Oral Cavity1: Area of Oral Cavity2: Area of Oral Cavity3: Area of Oral Cavity4: Area of Oral Cavity5: Area of Oral Cavity6: Area of Oral Cavity7: Area of Oral Cavity8: Area of Oral Cavity9: Area of Oral Cavity10:

26: Tooth System1: Tooth System2: Tooth System3: Tooth System4: Tooth System5: Tooth System6: Tooth System7: Tooth System8: Tooth System9: Tooth System10:

27: Tooth Number1: Tooth Number2: Tooth Number3: Tooth Number4: Tooth Number5: Tooth Number6: Tooth Number7: Tooth Number8: Tooth Number9: Tooth Number10:

28: Tooth Surface1: Tooth Surface2: Tooth Surface3: Tooth Surface4: Tooth Surface5: Tooth Surface6: Tooth Surface7: Tooth Surface8: Tooth Surface9: Tooth Surface10:

29: Procedure Code1: Procedure Code2: Procedure Code3: Procedure Code4: Procedure Code5: Procedure Code6: Procedure Code7: Procedure Code8: Procedure Code9: Procedure Code10:

29a: Diag Pointer1: Diag Pointer2: Diag Pointer3: Diag Pointer4: Diag Pointer5: Diag Pointer6: Diag Pointer7: Diag Pointer8: Diag Pointer9: Diag Pointer10:

30 Description1: 31: Fee1000-1: Fee100-1: Fee10-1: Fee1000-2: Fee100-2: Fee10-2: Fee1000-3: Fee100-3: Fee10-3: Fee1000-4: Fee100-4: Fee10-4: Fee1000-5: Fee100-5: Fee10-5: Fee1000-6: Fee100-6: Fee10-6: Fee1000-7: Fee100-7: Fee10-7: Fee1000-8: Fee100-8: Fee10-8: Fee1000-9: Fee100-9: Fee10-9: Fee1000-10: Fee100-10: Fee10-10:

30 Description2: 30 Description3: 30 Description4: 30 Description5: 30 Description6: 30 Description7: 30 Description8: 30 Description9: 30 Description10: 31a: Other Fees1000-1: Other Fees100-1: Other Fees10-1:

32: Total Fee1000-1: Total Fee100-1: Total Fee10-1:

33: Missing Teeth1: Missing Teeth2: Missing Teeth3: Missing Teeth4: Missing Teeth5: Missing Teeth6: Missing Teeth7: Missing Teeth8: Missing Teeth9: Missing Teeth10: Missing Teeth11: Missing Teeth12: Missing Teeth13: Missing Teeth14: Missing Teeth15: Missing Teeth16: Missing Teeth17: Missing Teeth18: Missing Teeth19: Missing Teeth20: Missing Teeth21: Missing Teeth22: Missing Teeth23: Missing Teeth24: Missing Teeth25: Missing Teeth26: Missing Teeth27: Missing Teeth28: Missing Teeth29: Missing Teeth30: Missing Teeth31: Missing Teet32: Missing TeethA: Missing TeethB: Missing TeethC: Missing TeethD: Missing TeethE: Missing TeethF: Missing TeethG: Missing TeethH: Missing TeethI: Missing TeethJ: Missing TeethK: Missing TeethL: Missing TeethM: Missing TeethN: Missing TeethO: Missing TeethP: Missing TeethQ: Missing TeethR: Missing TeethS: Missing TeethT:

34: Diag: Code1: Code2:

34a: Diag: CodeA: CodeB: CodeC: CodeD:

35: Remarks: Date:

37: Date:

38: Check Box1: Off Check Box2: Off Check Box3: Off Check Box4: Off

39: Number of Enclosures1: Number of Enclosures2: Number of Enclosures3:

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41: Date:

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44: Date:

45: Check Box1: Off Check Box2: Off Check Box3: Off

46: Date:

47: State:

48: Name: Address:

49: NPI:

50: License No:

51: SSN:

52: Area code: Ph No1: Ph No2:

52a: Additional Provider ID:

53: Date:

54: NPI:

55: License No:

56: Address: City, State Zip:

56a: Provider Specialty Code:

57: Area code: Ph No1: Ph No2:

58: Additional Provider ID: