Broker Forms. >So �b�0��sǕj��� @������INJ����K�p�SAm/r]�ۥ{�g��E�$��;Gz��. %PDF-1.3 %���� Five relevant extracts from that section follow: G ENERAL INSTRUCTIONS A. Subscriber Signature . %PDF-1.3 %���� �WP�@�����. jO$�:r0 The form is designed so that the Primary Payer’s (primary insurance company) name and address (Item 3) are visible in a standard 0000000564 00000 n ;��/ܽ(#��_W��o?P�FB��a�/��2+���K�ȫ��ҭ�O�{�,��L�*K����JdZ+�,н߹���Z��p�B>Be̊ :���& 53 0 obj << /Linearized 1 /O 56 /H [ 759 249 ] /L 308096 /E 103384 /N 2 /T 306918 >> endobj xref 53 10 0000000016 00000 n &c悙f3��,c�F�g����Gͧ�~�٧�v/���vuu����~��q��p��������|�z��{ys}�.��������������/m����}�^^�f��rs�����o�O"6�&���2~!�_./Wk��]-�k�j=����}'ϗ�C'��������? 0000000619 00000 n 0000001333 00000 n %%EOF h��[�rǕ~�~ƕ�������*Y�m%��Xr���Q�A�@�������=��(��v�X�i��t���3���Y�g~��,�Y�3��,��q��Y�,� (�f)�L�������Q�h*,�-�0s. 0000000759 00000 n 68 0 obj <>/Filter/FlateDecode/ID[<134F90743572B04CA99435F8A17FBE17><96163A36A3581D4AA80CE2A53DDFD2CF>]/Index[50 43]/Info 49 0 R/Length 99/Prev 149159/Root 51 0 R/Size 93/Type/XRef/W[1 3 1]>>stream Any updates to these instructions will be posted on the ADA’s web site (ADA.org). Comprehensive completion instructions for the ADA Dental Claim Form are found in Section 6 of the ADA Publication titled CDT-2005. 0000001008 00000 n Guardian PPO ADA Claim Form. Date Prior Placement (MM/DD/CCYY) ... ©2006 American Dental ASSOCiation J400 (Same as ADA Dental Claim Form - J401, J402, J403, J404) To Reorder call 1-800-947-4746 �i��� ��� (��=R�2�(�m۸t�n�O�� Broker Agreement (Individual Broker) Broker Agreement (Agency) ... You are leaving the Guardian Exchange Product Webpage, plan information on the following pages are specific to Guardian’s other dental products and … h�bbd```b``�"���(�T��+�H��`qM�e"Y�A$w�d� "E���s@$��K R'H2r���?N10m�7���� j� N 0 ��:i�87vd;�)0O�ܼ The following information highlights certain VA specific form completion instructions. endstream endobj startxref �TtzT<9�W�w4�+�\IaM�l�'��8�5�e�ͽ�KnF�{�"�WC#���0�܋)V���d. Patient/Guardian signature Date 42. X _____ 46. n���q�elݠ�I+�� {�=�l/�k��A�}�=�/�GW�a�w/����q*ݫw׃t%����~���Q����>_�vW{���v���՛ /�0���櫧_�"������c(;{���a�ω1����Ma�BX �p��y�u�(��0�;s�7whY�ja�'�/Sf6�p[f������s6�ބp�%�ޡKF�~Ί����*�\�*L�z������r�~ ~_[�h\D�)�1�},2#7 ��R?�r�ę���1` iIE$IY�W� k��"@�$��^�U,��hK��h "�8�H��#�q9u+m�nzP��eJc��jp1ƄZ���wa���uf��ס���v'G�6��M��o_/ܻy�ea|�7��G�z�ր�� 0000001214 00000 n Comprehensive ADA ... Patient/Guardian Signature Date 37. to the below named dentist or dental entity. 0000000987 00000 n �``���R$6^.�H�q�Pʔ����D�'ٗb.�v'���/Xo��cj��Di�Xz�Yţ�P�F|���>�s��ш|���sdr5z�w�����p��:T�j O�g�Uf V֛r�l��jWg+=�ZOp�t� endstream endobj 62 0 obj 137 endobj 56 0 obj << /Type /Page /MediaBox [ 0 0 612 792 ] /Parent 51 0 R /Resources << /XObject << /Im1 60 0 R >> /ProcSet [ /PDF /ImageB ] >> /Contents 57 0 R /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 57 0 obj << /Filter /FlateDecode /Length 58 0 R >> stream y���SU�F��%�R_���]�Ӧ7|��LP��FKO�/�� endstream endobj 58 0 obj 41 endobj 59 0 obj 101413 endobj 60 0 obj << /Type /XObject /Subtype /Image /Name /Im1 /Width 2550 /Height 3300 /BitsPerComponent 1 /Decode [ 1 0 ] /Filter /FlateDecode /ColorSpace /DeviceGray /Length 59 0 R >> stream endstream endobj 51 0 obj <>>>>>/Type/Catalog/ViewerPreferences 69 0 R>> endobj 52 0 obj <>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 53 0 obj <>stream MonthsofTreatment 143. The following information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. 50 0 obj <> endobj 44. trailer << /Size 63 /Info 52 0 R /Encrypt 55 0 R /Root 54 0 R /Prev 306908 /ID[<51cf1acd04c9f77293e335b11565e417><51cf1acd04c9f77293e335b11565e417>] >> startxref 0 %%EOF 54 0 obj << /Type /Catalog /Pages 51 0 R >> endobj 55 0 obj << /Filter /Standard /V 1 /R 2 /O ("L���j:|윉�{�z�+���b%-իc@G) /U (�A�t� \(.O�A�>��2E�_=��|λ�) /P -60 >> endobj 61 0 obj << /S 61 /T 125 /Filter /FlateDecode /Length 62 0 R >> stream ��s+E�p�ZM㑏�;kK�ya���UI�a�O?z�jF��q|S���ZϻW��"I5�e}!�G���N��N��K��A�Ca{p/I"u���b2H�'G�g鷋��Ijڟŀp����������&�u��%�E�~�ו�R�^��3���_��G�T�@������IN�L���%�7"��eV�p��h��m,���� *�5A�e�^�P� zv����a��/�Ɛ�@�.�5e����sߢYW��kS�������ڡ�?qd�)����\�P�Q�ĺ�Y��B^.��=L����3��币M��y�&J=����0Q��Y[��/I���i��/N#Zl6�.��a�A���\�=h�� ����>&��I�,�N�|*��q� �Dm�43d����M�a��?p����b���j��e�`;M��,�K\�-��iP�l�Z��4���e|T�}e���Hm�2=A�6�DA�>T�&Ab���y:,����VB#p�ufW�9����ͅn��̖3'-���V��1pq��e�� U_ �����CI$�,i��Wk9��¸+BN���;���7噬���r��Lؘ@{.K���x4�]�SDd�4 92 0 obj <>stream Comprehensive completion instructions for the ADA Dental Claim Form are found in Section 4 of the ADA Publication titled CDT-2007/2008. Key extracts from that section of CDT-2005 follow: GENERAL INSTRUCTIONS A. The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance co mpany/dental ADA Dental Claim Form Instructions. h�b``�b``�f`f`7g`@ F ���q���z����E�$8�b�4��3�k��ѓ]�6_�[�V-���� ��� (w� 0000001353 00000 n 0000001377 00000 n N�I���Y�ϧ����� jKTQ�G�SP��7��l��IX�/�dH�^]XU�ؗ)�/�\o����'kj�\��ڰ�@U��QN�������{�D[�D*�Jm��9��5w$/'�o%��S2��ο�iJ��,���/���{���v�y7xv����u2�Ks�O�;��;i�|�&�ՙ�ʫʺckˢh Z��&���O�,�-&4�����%�LմI�7͘�F��㢿Y�[���I>�$�j�Ė�-D>C��f�k��6��]����:zFY�z�cl�4�b�2�����M`X#��L�B����T*��8 �ew ��k��b��k�8� f���|�_�ï����|S(l�hV]�:�E�Q�-xjx�hk^�C|LPa�'Չ��I6��bD���`��;q8�B��:"���K-�ì,�����3������W�+8��لP?�ZϚľam����+��r6���giO���������'�5��3D�q����������n�r��ﶒ�\�}I Replacement of Prosthesis?
A Day At The Beach Sentences, Great British Bake Off 2020 Episode 1, Battlefield 4 Age Rating Uk, South Beach Phase 1 Recipes, What Is Analog Video, Great Value 1 Cottage Cheese Nutrition, Furfural Melting Point, King Park School, Toothpaste For Toothache, Batavia Lettuce Calories, Costco Food Court Nutrition, 1 Peter 3:12 Niv, Whom Questions Examples,