[FORM OPTIONS] MAXLINES = 10 LINEHEIGHT=0.18675 [END FORM OPTIONS] [MARGINS] Top = 0.0 Left = 0.0 Right = 0.0 Bottom = 0.0 [END MARGINS] [FONTS] Font 1 = Arial, 8, Normal Font 2 = Arial, 6, Bold, Silver Font 3 = Arial, 7, Bold, Silver Font 4 = MS San Serif, 6, Normal, Silver Font 5 = Arial Narrow, 10, Bold, Silver Font 6 = Arial, 6, Normal, Silver Font 7 = Arial, 13, Bold, Silver Font 8 = Arial, 4, Normal, Silver Font 9 = Arial, 10, Normal, Black Font 10 = MS Sans Serif, 8, Normal, Black Font 11 = Arial, 6, Bold, Black Font 12 = Arial, 6, Normal, Black Font 13 = Arial, 8, Bold, Black Font 14 = Arial, 7, Bold, Black Font 15 = Arial, 5, Bold, Black Font 16 = Arial, 9, Normal, Black [END FONTS] [PATIENT INFORMATION] [If Bill:Estimate = TRUE] ["x",1.96875,0.625,.25,Left,Font 9]; [else] ["x",0.40625,0.625,0.250,LEFT,Font 9]; [endif] [If Bill:EPSDT <> ""] ["x",0.40625,0.8125,0.250,LEFT,Font 9]; [endif] [Bill:Ins1_Prior,0.344,1.125,1,Left,Font 9]; [IF Bill:ins1_type <> "2"] [Guarantor1:Lastname + ", " + Guarantor1:Firstname + " " + Guarantor1:Middle,4.365,1.354,3.792,LEFT,Font 9]; [Guarantor1:Address1 + " " + Guarantor1:Address2,4.375,0.000,3.802,LEFT,Font 9]; [ELSE] ; ; [ENDIF] [Primary:Company,0.344,,3,Left,Font 9] [IF Bill:ins1_type <> "2"] [Guarantor1:City + " " + Guarantor1:State + " " + Guarantor1:Zip,4.375,0.000,3.802,LEFT,Font 9]; [ELSE] ; [ENDIF] [Primary:Address1 + " " + Primary:Address2,0.344,0.000,3.823,LEFT,Font 9]; [Primary:City + " " + Primary:State + " " + Primary:Zip,0.344,0.000,3.823,LEFT,Font 9] [IF Bill:ins1_type <> "2"] [Guarantor1:Birthdate,4.375,2.156,1.000,LEFT,Font 9] [If Guarantor1:Sex = "M"] ["x",5.9375,2.125,.25,Left,Font 9] [Endif] [If Guarantor1:Sex = "F"] ["x",6.218,2.125,.25,Left,Font 9] [Endif] [Bill:Ins1_ID,6.688,0.000,1.500,LEFT,Font 9]; [ENDIF] [If Bill:Ins2_Code = ""] ["x",1.844,2.531,0.250,LEFT,Font 9] [else] ["x",2.90625,2.531,.25,Left,Font 9] [endif] [IF Bill:ins1_type <> "2"] [Bill:Ins1_Group,4.375,2.438,1.198,LEFT,Font 9] [Employer1:Company,5.750,0.000,2.406,LEFT,Font 9] [ENDIF] ; [GUARANTOR2:BIRTHDATE,0.375,3.188,1.219,LEFT,Font 9] [If Bill:Ins2_Code <> ""] [IF GUARANTOR2:SEX = "M"] ["x",1.813,3.188,0.250,LEFT,Font 9] [endif] [if guarantor2:sex = "F"] ["x",2.125,3.1875,0.25,Left,Font 9] [endif] [guarantor2:SS,2.500,3.188,1.677,LEFT,Font 9] [ENDIF] [IF Bill:Ins1_GRel = "M"] ["x",4.531,2.948,0.250,LEFT,Font 9] [Endif] [IF Bill:Ins1_GRel = "S"] ["x",5.031,2.948,0.250,LEFT,Font 9] [ENDIF] [IF Bill:Ins1_GRel = "P"] ["x",5.625,2.948,0.250,LEFT,Font 9] [Endif] [IF Bill:Ins1_GRel = "O"] ["x",6.5625,2.948,0.250,LEFT,Font 9] [ENDIF] [If Patient:School <> ""] [If Patient:Full_Time = True] ["x",7.1875,2.948,0.250,LEFT,Font 9] [endif] [if Patient:Full_Time = False] ["x",7.719,2.948,0.250,LEFT,Font 9] [endif] [endif] [Patient:LastName + " " + Patient:FirstName + " " + Patient:Middle,4.375,3.313,3.792,LEFT,Font 9]; [Bill:Ins2_Group,0.344,3.531,1.333,LEFT,Font 9] [If Bill:Ins2_Code <> ""] [IF Bill:Ins2_GRel = "M"] ["x",1.813,3.531,0.344,LEFT,Font 9] [Endif] [IF Bill:Ins2_GRel = "S"] ["x",2.344,3.531,0.313,LEFT,Font 9] [ENDIF] [IF Bill:Ins2_GRel = "P"] ["x",2.969,3.531,0.365,LEFT,Font 9] [Endif] [IF Bill:Ins2_GRel = "O"] ["x",3.656,3.531,0.250,LEFT,Font 9] [ENDIF] [Endif] [Patient:Address1 + " " + Patient:Address2,4.375,3.510,3.802,LEFT,Font 9]; [Patient:City + " " + Patient:State + " " + Patient:Zip,4.375,0.000,3.802,LEFT,Font 9]; [Patient:BIRTHDATE,4.385,4.063,1.000,LEFT,Font 9] [IF Patient:Sex = "M"] ["x",5.833,4.094,0.250,LEFT,Font 9] [ELSE] ["x",6.135,4.104,0.198,LEFT,Font 9] [ENDIF] ["x",4.438,7.615,0.250,LEFT,Font 9] [Bill:radio_no,6.938,7.656,0.250,LEFT,Font 9]; [If bill:ortho <> "True"] ["x",4.531,7.927,0.250,LEFT,Font 9] [else] ["x",5.354,7.927,0.250,LEFT,Font 9] [endif] [if bill:ortho = "True"] [bill:ortho_date,6.813,7.948,1.000,LEFT,Font 9] [bill:ortho_mos,5.083,8.302,0.250,LEFT,Font 9] [endif] [if bill:pros_reas <>""] ["x",5.719,8.302,0.250,LEFT,Font 9] [bill:pros_date,6.750,8.302,1.000,LEFT,Font 9] [endif] [if bill:pros_init = "true"] ["x",5.406,8.302,0.250,LEFT,Font 9] [endif] [if bill:acc_occup = "true"] ["x",4.531,8.667,0.250,LEFT,Font 9] [Bill:acc_date,5.813,8.875,0.948,LEFT,Font 9] [endif] [if bill:acc_auto = "true"] ["x",6.031,8.667,0.250,LEFT,Font 9] [Bill:acc_date,5.813,8.875,0.927,LEFT,Font 9] [endif] [if bill:acc_other = "true"] ["x",7.031,8.667,0.250,LEFT,Font 9] [Bill:acc_date,5.813,8.875,0.938,LEFT,Font 9] [endif] [IF Patient:Sig_Info = True] ["Signature on file",0.479,8.021,2.010,LEFT,Font 9] [{Today},2.563,0.000,1.667,LEFT,Font 9] [ENDIF] [IF Patient:Sig_Assign = True] ["Signature on file",0.521,8.698,2.010,LEFT,Font 9] [{Today},2.594,0.000,1.635,LEFT,Font 9] [ENDIF] [IF Practice:eid > " "] [Practice:eid,3.073,10.344,1.104,LEFT,Font 1] [ELSE] [Employee:SS,3.073,10.344,1.104,LEFT,Font 1] [ENDIF] [employee:phone,0.917,10.573,1.000,LEFT,Font 9] [employee:phone,5.135,10.573,1.000,LEFT,Font 9] [Guarantor2:Lastname + " " + Guarantor2:FirstName + " " + Guarantor2:Middle,0.344,2.823,3.813,LEFT,Font 9] [IF bill:ins2_code <> ""] [Secondary:COMPANY,0.365,3.823,3.792,LEFT,Font 9] [Secondary:Address1 + " " + Secondary:Address2,0.375,3.990,3.781,LEFT,Font 9] [Secondary:City + " " + Secondary:State + " " + Secondary:Zip,0.375,4.135,3.771,LEFT,Font 9] [ENDIF] [IF Bill:ins1_type <> "2"] [Patient:Code,6.625,4.063,1.500,LEFT,Font 9] [ELSE] [Bill:Ins1_ID,6.625,4.063,1.500,LEFT,Font 9] [ENDIF] ; ; ; ; [END PATIENT INFORMATION] [CLAIM TOTAL] [Dollars({Charges}),7.5,6.875,0.50,RIGHT,Font 1] [Cents({Charges}),7.6875,0.000,0.5,RIGHT,Font 1] [{Notes1},0.417,7.115,7.760,LEFT,Font 1]; ["Signature on File",4.542,9.563,3.000,LEFT,Font 1] [Employee:custom2,0.500,10.365,1.000,LEFT,Font 1] [Employee:license,1.698,10.365,1.125,LEFT,Font 1] [Practice:address1,4.677,10.208,2.000,LEFT,Font 1] [Practice:city + " " + Practice:state + " " + Practice:zip,4.688,10.344,2.000,LEFT,Font 1] [{Today},6.906,9.563,1.240,LEFT,Font 1] [Employee:custom1,4.740,9.896,1.083,LEFT,Font 1] [Employee:license,7.115,9.896,1.083,LEFT,Font 1] ["1223G0001X",7.021,10.052,1.083,LEFT,Font 1] [Employee:Title,0.375,9.615,3.000,LEFT,Font 9] [Practice:address1,0.375,9.760,3.000,LEFT,Font 9] [Practice:city + " " + Practice:state + " " + Practice:Zip,0.365,9.948,3.000,LEFT,Font 9] [END CLAIM TOTAL] [SERVICE DETAIL] [if bill:estimate <> "True"] [Detail:date,0.4375,0.000,1.000,LEFT,Font 9] [endif] [detail:tooth,2.25,,1,Left,Font 9] [detail:surface,3.25,0.000,1.000,LEFT,Font 9] [fee:ada_code,3.844,0.000,1.000,LEFT,Font 9] [detail:desc,4.500,0.000,2.906,LEFT,Font 9] [Dollars(Detail:Extended),7.50,0.000,0.500,RIGHT,Font 1] [Cents(Detail:Extended),7.6875,0.000,0.500,RIGHT,Font 1]; [END SERVICE DETAIL] [INSURANCE FORM] ["ADA Dental Claim Form",0.250,0.146,1.750,LEFT,Font 9] [{Box,0.250,0.323,4.000,4.000,6,Black,Black}] [{Box,0.250,0.490,4.000,0.521,1,Black,Black}] [{Box,4.250,2.625,4.000,1.688,6,Black,Black}] [{Box,4.250,0.938,4.000,3.375,6,Black,Black}] [{Box,0.250,1.313,4.000,1.000,6,Black,Black}] [{Box,0.250,4.302,8.000,3.000,6,Black,Black}] [{Box,0.250,7.000,8.000,3.781,6,Black,Black}] [{Box,0.250,6.510,6.740,0.490,6,Black,Black}] [{Box,0.250,9.021,8.000,1.740,6,Black,Black}] [{Box,0.250,7.302,4.052,3.469,6,Black,Black}] [{Box,0.250,1.313,4.000,0.208,1,Black,Black}] [{Box,0.250,2.313,4.000,0.156,1,Black,Black}] [{Box,0.250,2.688,4.000,0.344,1,Black,Black}] [{Box,0.250,3.375,4.000,0.344,1,Black,Black}] [{Box,4.250,0.938,4.000,0.188,1,Black,Black}] [{Box,4.250,2.000,4.000,0.344,1,Black,Black}] [{Box,5.688,2.000,0.750,0.344,1,Black,Black}] [{Box,4.250,2.635,4.000,0.167,1,Black,Black}] [{Box,4.250,2.802,4.000,0.323,1,Black,Black}] [{Box,6.979,2.802,1.271,0.323,1,Black,Black}] [{Box,4.250,3.948,4.000,0.365,1,Black,Black}] [{Box,5.823,4.125,0.125,0.125,1,Black,Black}] [{Box,0.250,4.302,8.000,0.156,1,Black,Black}] [{Box,0.250,4.458,8.000,0.313,1,Black,Black}] [{Box,0.385,4.458,1.052,2.052,1,Black,Black}] [{Box,1.750,4.458,0.292,2.052,1,Black,Black}] [{Box,3.156,4.458,0.573,2.052,1,Black,Black}] [{Box,4.271,4.458,3.229,2.052,1,Black,Black}] [{Box,0.260,4.938,8.000,1.573,1,Black,Black}] [{Box,0.250,5.115,8.000,1.229,1,Black,Black}] [{Box,0.250,5.281,8.000,0.885,1,Black,Black}] [{Box,0.250,5.438,8.000,0.531,1,Black,Black}] [{Box,0.250,5.604,8.000,0.188,1,Black,Black}] [{Box,0.250,6.510,6.740,0.156,1,Black,Black}] [{Box,1.833,6.667,3.229,0.333,1,Black,Black}] [{Box,3.469,6.667,2.563,0.333,1,Black,Black}] [{Box,1.833,6.667,5.146,0.156,1,Black,Black}] [{Box,6.969,6.510,1.260,0.302,1,Black,Black}] [{Box,6.969,6.510,0.531,0.302,1,Black,Black}] [{Box,6.979,6.813,0.594,0.177,1,Black,Black}] [{Box,0.250,7.292,8.000,0.156,1,Black,Black}] [{Box,0.250,7.438,4.063,0.906,1,Black,Black}] [{Box,4.313,9.021,3.927,0.208,1,Black,Black}] [{Box,4.313,7.438,3.927,0.365,1,Black,Black}] [{Box,4.313,7.802,3.927,0.354,1,Black,Black}] [{Box,4.313,8.146,3.927,0.375,1,Black,Black}] [{Box,4.313,8.521,3.917,0.333,1,Black,Black}] [{Box,0.260,10.542,7.990,0.229,1,Black,Black}] [{Box,4.313,9.240,3.927,0.657,1,Black,Black}] [{Box,4.313,9.240,3.927,0.802,1,Black,Black}] [{Box,6.281,9.885,1.958,0.313,1,Black,Black}] [{Box,0.250,9.031,4.063,0.323,1,Black,Black}] [{Box,0.250,9.354,4.052,0.885,1,Black,Black}] [{Box,1.563,10.240,1.313,0.302,1,Black,Black}] ["Statement of Actual Services",0.563,0.688,1.500,LEFT,Font 2] ["EPSDT/Title XIX",0.563,0.833,1.500,LEFT,Font 2] [{Box,0.375,0.656,0.125,0.125,1,Black,Black}] [{Box,0.375,0.813,0.125,0.125,1,Black,Black}] [{Box,2.000,0.656,0.125,0.125,1,Black,Black}] ["3. Company/Plan Name, Address, City, State, Zip Code",0.375,1.531,2.354,LEFT,Font 11] ["Request for Predetermination/Preauthorization",2.188,0.688,1.917,LEFT,Font 2] ["4. Other Dental or Medical Coverage?",0.375,2.563,1.490,LEFT,Font 11] ["No (Skip 5-11)",2.063,2.563,0.646,LEFT,Font 11] [{Box,1.875,2.531,0.125,0.125,1,Black,Black}] [{Box,2.885,2.531,0.125,0.125,1,Black,Black}] [{Box,1.688,3.042,0.677,0.333,1,Black,Black}] ["7. Gender",1.750,3.063,0.542,LEFT,Font 11] ["M",1.938,3.219,0.073,LEFT,Font 11] ["F",2.240,3.219,0.052,LEFT,Font 11] [{Box,1.781,3.188,0.125,0.125,1,Black,Black}] [{Box,2.094,3.188,0.125,0.125,1,Black,Black}] ["8. Subscriber Identifier (SSN or ID#)",2.500,3.063,1.448,LEFT,Font 11] ["9. Plan/Group Number",0.375,3.406,1.125,LEFT,Font 11] [{Box,0.250,3.375,1.448,0.344,1,Black,Black}] ["Self",1.969,3.563,0.146,LEFT,Font 11] ["Spouse",2.448,3.563,0.375,LEFT,Font 11] ["Dependent",3.063,3.563,0.458,LEFT,Font 11] ["Other",3.781,3.563,0.292,LEFT,Font 11] [{Box,1.781,3.552,0.125,0.125,1,Black,Black}] [{Box,2.313,3.552,0.125,0.125,1,Black,Black}] [{Box,2.938,3.552,0.125,0.125,1,Black,Black}] [{Box,3.625,3.552,0.125,0.125,1,Black,Black}] ["HEADER INFORMATION",0.385,0.354,1.365,LEFT,Font 13] ["INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION",0.333,1.354,3.5,LEFT,Font 13] ["OTHER COVERAGE",0.375,2.333,1.156,LEFT,Font 13] ["1. Type of Transaction (Mark all applicable boxes)",0.375,0.500,3.000,LEFT,Font 2] ["12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code",4.323,1.156,3.885,LEFT,Font 11] ["13. Date of Birth (MM/DD/CCYY)",4.375,2.031,1.250,LEFT,Font 11] ["14. Gender",5.844,2.031,0.510,LEFT,Font 11] ["M",6.063,2.156,0.073,LEFT,Font 11] ["F",6.344,2.156,0.052,LEFT,Font 11] [{Box,5.906,2.146,0.125,0.125,1,Black,Black}] ["POLICY HOLDER/SUBSCRIBER INFORMATION",4.344,0.990,2.271,LEFT,Font 14] ["(for Insurance Company Named in #3)",6.583,1.000,1.500,LEFT,Font 11] [{Box,6.198,2.146,0.125,0.125,1,Black,Black}] ["15. Policyholder/Subscriber ID (SSN or ID#)",6.458,2.031,1.708,LEFT,Font 11] [{Box,4.260,2.344,1.333,0.281,1,Black,Black}] ["16. Plan/Group Number",4.375,2.333,0.990,LEFT,Font 11] ["17. Employer Name",5.750,2.354,0.854,LEFT,Font 11] ["PATIENT INFORMATION",4.365,2.667,1.271,LEFT,Font 13] ["18. Relationship to Policyholder/Subscriber in #12 above",4.365,2.823,2.583,LEFT,Font 11] ["19. Student Status",7.021,2.813,0.802,LEFT,Font 11] ["Self",4.688,3.000,0.146,LEFT,Font 11] ["Spouse",5.188,3.000,0.396,LEFT,Font 11] ["Dependent Child",5.792,3.000,0.729,LEFT,Font 11] ["Other",6.688,3.000,0.219,LEFT,Font 11] [{Box,4.500,2.969,0.125,0.125,1,Black,Black}] [{Box,5.000,2.969,0.125,0.125,1,Black,Black}] [{Box,5.594,2.969,0.125,0.125,1,Black,Black}] [{Box,6.510,2.969,0.125,0.125,1,Black,Black}] ["21. Date of Birth (MM/DD/CCYY)",4.323,3.979,1.323,LEFT,Font 11] ["22. Gender",5.781,3.979,0.531,LEFT,Font 11] ["23. Patient ID/Account #(Assigned by Dentist)",6.385,3.979,1.802,LEFT,Font 11] ["M",6.000,4.125,0.073,LEFT,Font 11] ["F",6.260,4.125,0.083,LEFT,Font 11] [{Box,5.594,3.948,0.792,0.365,1,Black,Black}] [{Box,6.115,4.125,0.125,0.125,1,Black,Black}] ["RECORD OF SERVICES PROVIDED",0.375,4.333,2.563,LEFT,Font 13] ["Surface",3.302,4.615,0.323,LEFT,Font 11] ["1",0.323,4.802,0.031,LEFT,Font 11] ["2",0.333,4.990,0.042,LEFT,Font 11] ["3",0.323,5.156,0.042,LEFT,Font 11] ["4",0.323,5.313,0.042,LEFT,Font 11] ["5",0.323,5.479,0.042,LEFT,Font 11] ["6",0.323,5.646,0.042,LEFT,Font 11] ["7",0.323,5.823,0.042,LEFT,Font 11] ["8",0.323,6.021,0.042,LEFT,Font 11] ["9",0.323,6.198,0.042,LEFT,Font 11] ["10",0.292,6.375,0.083,LEFT,Font 11] [{Box,0.250,6.531,1.583,0.458,1,Black,Black}] ["MISSING TEETH INFORMATION",0.323,6.531,1.490,LEFT,Font 14] ["Permanent",3.219,6.552,0.531,LEFT,Font 11] [{Box,5.052,6.531,1.948,0.469,1,Black,Black}] ["Primary",5.927,6.552,0.479,LEFT,Font 11] ["1 2 3 4 5 6 7 8",1.833,6.698,1.646,CENTER,Font 11] ["A B C D E ",5.042,6.708,1.000,CENTER,Font 11] [" F G H I J",6.010,6.688,0.906,CENTER,Font 11] ["32. Other",7.063,6.542,0.385,LEFT,Font 11] ["Fee(s)",7.094,6.656,0.240,LEFT,Font 11] ["33. Total Fee",7.031,6.865,0.521,LEFT,Font 11] ["35. Remarks",0.323,7.031,0.594,LEFT,Font 11] ["AUTHORIZATIONS",0.323,7.313,1.042,LEFT,Font 13] ["ANCILLARY CLAIM/TREATMENT INFORMATION",4.406,7.313,2.563,LEFT,Font 13] ["36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all",0.375,7.490,3.865,LEFT,Font 15] ["charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or",0.375,7.594,3.760,LEFT,Font 15] ["the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of",0.375,7.708,3.833,LEFT,Font 15] ["such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health",0.375,7.802,3.583,LEFT,Font 15] ["information to carry out payment activities in connection with this claim.",0.385,7.896,2.427,LEFT,Font 15] ["38. Place of Treatment",4.365,7.458,2.167,LEFT,Font 11] ["Provider's Office",4.552,7.635,0.667,LEFT,Font 11] ["Hospital",5.427,7.635,0.385,LEFT,Font 11] ["ECF",5.938,7.635,0.198,LEFT,Font 11] ["Other",6.323,7.635,0.219,LEFT,Font 11] ["39. Number of Enclosures (00 to 99)",6.667,7.458,1.479,LEFT,Font 11] ["Radiograph(s)",6.802,7.573,0.479,LEFT,Font 15] ["Model(s)",7.885,7.573,0.291,LEFT,Font 15] [{Box,6.885,7.656,0.219,0.125,1,Black,Black}] [{Box,7.396,7.656,0.219,0.125,1,Black,Black}] [{Box,7.896,7.656,0.219,0.125,1,Black,Black}] ["40. Is Treatment for Orthodontics?",4.365,7.813,1.365,LEFT,Font 11] [{Box,6.583,7.448,1.656,1.083,1,Black,Black}] [{Box,4.510,7.979,0.125,0.115,1,Black,Black}] [{Box,5.323,7.979,0.125,0.115,1,Black,Black}] ["No (Skip 41-42)",4.698,7.990,0.646,LEFT,Font 11] ["Yes (Complete 41-42)",5.615,7.990,0.958,LEFT,Font 11] ["42. Months of Treatment",4.344,8.167,0.979,LEFT,Font 11] ["Remaining",4.469,8.260,0.417,LEFT,Font 11] [{Box,5.323,8.146,1.260,0.375,1,Black,Black}] ["43. Replacement of Prosthesis?",5.323,8.167,1.208,LEFT,Font 11] [{Box,5.375,8.344,0.125,0.115,1,Black,Black}] [{Box,5.708,8.344,0.125,0.115,1,Black,Black}] ["No",5.521,8.354,0.115,LEFT,Font 11] ["Yes (Complete 44)",5.854,8.354,0.781,LEFT,Font 11] ["45. Treatment Resulting from",4.375,8.552,2.177,LEFT,Font 11] [{Box,4.510,8.719,0.125,0.115,1,Black,Black}] [{Box,6.000,8.708,0.125,0.115,1,Black,Black}] [{Box,7.000,8.708,0.125,0.115,1,Black,Black}] ["Occupational illness/injury",4.698,8.708,1.135,LEFT,Font 11] ["Auto accident",6.219,8.708,0.635,LEFT,Font 11] ["Other accident",7.188,8.719,0.760,LEFT,Font 11] ["X________________________________________________________________________________________",0.344,8.073,3.875,LEFT,Font 13] ["Patient/Guardian Signature",0.385,8.188,1.531,LEFT,Font 11] ["37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named",0.375,8.396,3.906,LEFT,Font 15] ["X________________________________________________________________________________________",0.354,8.771,3.875,LEFT,Font 13] ["Subscriber signature",0.490,8.896,1.208,LEFT,Font 11] ["46. Date of Accident (MM/DD/CCYY)",4.333,8.906,1.729,LEFT,Font 11] ["47. Auto Accident State",6.792,8.906,0.948,LEFT,Font 11] ["BILLING DENTIST OR DENTAL ENTITY",0.323,9.104,2.073,LEFT,Font 13] ["(Leave blank if dentist or dental entity is not submitting",2.385,9.115,1.865,LEFT,Font 15] ["claim on behalf of the patient or insured/subscriber)",0.344,9.240,1.979,LEFT,Font 15] ["TREATING DENTIST AND TREATMENT LOCATION INFORMATION",4.417,9.063,3.594,LEFT,Font 13] ["48. Name, Address, City, State, Zip Code",0.375,9.396,1.677,LEFT,Font 11] ["49. NPI",0.354,10.271,0.656,LEFT,Font 11] ["50. License Number",1.583,10.260,1.104,LEFT,Font 11] ["51. SSN or TIN",2.896,10.260,1.250,LEFT,Font 11] ["52. Phone",0.365,10.542,1.021,LEFT,Font 11] ["Number",0.500,10.635,0.469,LEFT,Font 11] ["53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple",4.333,9.240,3.896,LEFT,Font 15] ["visits) or have been completed.",4.333,9.354,3.604,LEFT,Font 15] ["X_________________________________________________________",4.354,9.573,3.635,LEFT,Font 13] ["Signed (Treating Dentist)",4.448,9.750,1.333,LEFT,Font 11] ["Date",6.948,9.729,0.354,LEFT,Font 11] ["54. NPI",4.375,9.896,0.802,LEFT,Font 11] ["55. License Number",6.302,9.896,1.073,LEFT,Font 11] ["56. Address, City, State, Zip Code",4.375,10.052,1.979,LEFT,Font 11] ["56A. Provider",6.302,10.021,0.708,LEFT,Font 11] ["Specialty Code",6.302,10.104,0.750,LEFT,Font 11] ["52A. Additional",2.500,10.542,0.750,LEFT,Font 11] ["Provider ID",2.688,10.635,0.750,LEFT,Font 11] ["58. Additional",6.323,10.542,0.854,LEFT,Font 11] ["Provider ID",6.448,10.635,0.500,LEFT,Font 11] ["24. Procedure Date",0.531,4.500,0.906,LEFT,Font 15] ["(MM/DD/CCYY)",0.594,4.625,0.604,LEFT,Font 15] ["25. Area",1.448,4.458,0.292,LEFT,Font 15] ["of Oral",1.448,4.563,0.292,LEFT,Font 15] ["Cavity",1.458,4.656,0.240,LEFT,Font 15] ["26.",1.844,4.458,0.104,LEFT,Font 15] ["Tooth",1.771,4.552,0.240,LEFT,Font 15] ["System",1.760,4.646,0.271,LEFT,Font 15] ["or Letter(s)",2.354,4.604,0.542,LEFT,Font 15] ["28. Tooth",3.260,4.500,0.365,LEFT,Font 15] ["27. Tooth Number(s)",2.198,4.500,0.875,LEFT,Font 15] ["29. Procedure",3.729,4.500,0.521,LEFT,Font 15] ["30. Description",5.396,4.500,0.885,LEFT,Font 15] ["Code",3.865,4.615,0.208,LEFT,Font 15] ["31.Fee",7.635,4.500,0.469,LEFT,Font 15] ["41. Date Appliance Placed (MM/DD/CCYY)",6.604,7.823,1.594,LEFT,Font 15] ["44. Date Prior Placement (MM/DD/CCYY)",6.604,8.167,1.594,LEFT,Font 15] ["20. Name (Last, First, Middle Initial, Suffix), Address, City, Zip Code",4.375,3.188,3.375,LEFT,Font 11] ["34. (Place an 'X' on each missing tooth)",0.292,6.760,1.521,LEFT,Font 11] [{Box,4.385,7.635,0.125,0.125,1,Black,Black}] [{Box,5.260,7.635,0.125,0.125,1,Black,Black}] [{Box,5.781,7.635,0.125,0.125,1,Black,Black}] [{Box,6.146,7.635,0.125,0.125,1,Black,Black}] [{Box,7.167,2.969,0.125,0.125,1,Black,Black}] [{Box,7.698,2.969,0.125,0.125,1,Black,Black}] ["FTS",7.396,2.969,0.302,LEFT,Font 11] ["PTS",7.948,2.979,0.198,LEFT,Font 11] ["11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code",0.385,3.719,3.760,LEFT,Font 11] ["Date",2.688,8.188,0.219,LEFT,Font 11] ["Date",2.688,8.896,0.219,LEFT,Font 11] ["2. Predetermination / Preauthorization Number",0.375,1.031,2.802,LEFT,Font 11] ["Yes (Complete 5-11)",3.063,2.563,0.906,LEFT,Font 11] ["5. Name of Policy Holder/Subscriber in #4 (Last, First, Middle Initial, Suffix)",0.375,2.729,3.000,LEFT,Font 11] ["6. Date of Birth (MM/DD/CCYY)",0.375,3.063,1.219,LEFT,Font 11] ["10. Relationship to Primary Subscriber (Check applicable box)",1.698,3.406,2.479,LEFT,Font 11] ["Oral Image(s)",7.333,7.573,0.521,LEFT,Font 15] ["dentist or dental entry.",0.396,8.490,1.094,LEFT,Font 15] ["57. Phone",4.396,10.542,0.542,LEFT,Font 11] ["Number ",4.510,10.635,0.479,LEFT,Font 11] ["32 31 30 29 28 27 26 25",1.813,6.833,1.646,CENTER,Font 11] [" O N M L K",6.000,6.844,0.917,CENTER,Font 11] ["24 23 22 21 20 19 18 17 ",3.479,6.833,1.573,CENTER,Font 11] ["T S R Q P ",5.031,6.833,1.000,CENTER,Font 11] [" 9 10 11 12 13 14 15 16 ",3.500,6.708,1.531,CENTER,Font 11] [{Box,2.427,10.542,0.000,0.219,1,Black,Black}] [{Box,6.302,10.552,0.000,0.208,1,Black,Black}] [{Box,6.760,8.864,0.000,0.177,1,Black,Black}] [END INSURANCE FORM]