Dental Authorization / X-Ray Submission Form

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.

 

 For immediate results, use your dental software to submit predeterminations. When x-rays are required, please complete the form below.

 * 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: * () -
Email Address:  
Confirm Email Address:  
Patient Information
Carrier/Adjudicator/Third Party Payor: *  
Plan Member ID number. *   -
Given Name: *  
Last Name: *  
Date of Birth: *   [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)
18 17 16 15 14 13 12 11
21 22 23 24 25 26 27 28
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.
18 17 16 15 14 13 12 11
21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41
31 32 33 34 35 36 37 38
Authorization/Predetermination Information
Int’l Tooth Code Tooth Surfaces (e.g. MOD) Procedure Code* Provider's Fee* Laboratory Charges
Remove Row
Remove Row
Remove Row
Remove Row
Remove Row
Remove Row
Remove Row
Remove Row
Remove Row

Add another line
   
   
Comments  (limit 1000 characters)  0 *
File Attachments (Expertise statements, x-rays and/or photos may be attached.)
 * At minimum one upload is required.
1.
2.
3.
4.
5.
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.


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