Dental Authorization / X-Ray Submission Form

Many procedures do not require x-rays or digital photos for approval. We recommend you first submit your predetermination to us via your dental software. If you are unable to do so, providerConnect is an alternative to sending us x-rays or photos manually through the mail.

Dental X-Rays can be submitted to one of the providerConnect™ Participating Carriers/Adjudicators/Third Party Payors. You will find your unique Provider Number on your statement from the Participating Carriers/Adjudicators/Third Party Payors outlined in Schedule A within your Provider of Service Agreement – Health and Professional Services.

* indicates a mandatory field

Provider Information

If you sign into Secure Services, the provider information will be pre-populated, saving you time.

Name:

UIN #:

Street Address 1:

Street Address 2:

City:

Province:

Postal Code:

Telephone Number: Area Code Prefix Line number

() -

Email Address:

Confirm Email Address:

Patient Information

Carrier/Adjudicator/Third Party Payor:

Plan Member ID number:

Patient Given Name:

Patient Last Name:

Patient Date of Birth: years Month Day

[yyyy mm dd]

Street Address 1:

Street Address 2:

City:

Province:

Postal Code:

Patient History/Chart Information

Patient History - Bridges (A= Abutment P= Pontic I= Implant)

Patient History - Bridges1
18	17	16	15	14	13	12	11	21	22	23	24	25	26	27	28

Patient History - Bridges3
48	47	46	45	44	43	42	41	31	32	33	34	35	36	37	38

Patient History - Missing Teeth and Endodontic Treatments (E=Endo M=Missing)

Required information for a bridge or implant. Processing times will be delayed if not completed.

Patient History - Missing Teeth and Endodontic Treatments (E=Endo M=Missing)

Patient History

Patient History - 1
18	17	16	15	14	13	12	11	21	22	23	24	25	26	27	28

Patient History - 3
48	47	46	45	44	43	42	41	31	32	33	34	35	36	37	38

Authorization/Predetermination Information

Dental PDT info table

Dental PDT info
Int’l Tooth Code	Tooth Surfaces (e.g. MOD)	Procedure Code*	Provider's Fee*	Laboratory Charges

Dental PDT data entry

Int’l Tooth Code

Tooth Surfaces (e.g. MOD)

Procedure Code

Provider's Fee

Laboratory Charges

Remove Row

Dental PDT data entry

Int’l Tooth Code

Tooth Surfaces (e.g. MOD)

Procedure Code

Provider's Fee

Laboratory Charges

Remove Row

Dental PDT data entry

Int’l Tooth Code

Tooth Surfaces (e.g. MOD)

Procedure Code

Provider's Fee

Laboratory Charges

Remove Row

Dental PDT data entry

Int’l Tooth Code

Tooth Surfaces (e.g. MOD)

Procedure Code

Provider's Fee

Laboratory Charges

Remove Row

Dental PDT data entry

Int’l Tooth Code

Tooth Surfaces (e.g. MOD)

Procedure Code

Provider's Fee

Laboratory Charges

Remove Row

Dental PDT data entry

Int’l Tooth Code

Tooth Surfaces (e.g. MOD)

Procedure Code

Provider's Fee

Laboratory Charges

Remove Row

Dental PDT data entry

Int’l Tooth Code

Tooth Surfaces (e.g. MOD)

Procedure Code

Provider's Fee

Laboratory Charges

Remove Row

Dental PDT data entry

Int’l Tooth Code

Tooth Surfaces (e.g. MOD)

Procedure Code

Provider's Fee

Laboratory Charges

Remove Row

Dental PDT data entry

Int’l Tooth Code

Tooth Surfaces (e.g. MOD)

Procedure Code

Provider's Fee

Laboratory Charges

Remove Row

Add another line

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File Attachments (Expertise statements, x-rays and/or photos may be attached.)

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This is an approximation only.
Final laboratory charges will be included on claim form when treatment is completed.

By submitting this form, I acknowledge that the Plan Member has given written authorization to submit personal information to the Carrier/Adjudicator/Third Party Payor necessary for claims adjudication, and for the Carrier/Adjudicator/Third Party Payor to exchange information with other parties as required and only when the information is needed to administer this benefit claim and/or to confirm the accuracy of this information.

I agree that the information provided is complete and accurate, to the best of my knowledge.