Dental Claims Approval Form 2.0

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document_type=form entity=format:application/pdf language=en taxonomy_l1=economy_finance taxonomy_l2=insurance taxonomy_l3=health_insurance validity=valid validity_confidence=0.6

DCAF 2.0
To be completed & ID verified by the reception/nurse:
Provider Name:
Insurance Company Name:
TPA Company Name:
Patient File Number:
Date of visit / /
Plan Type ( ) | New visit ( ) | Follow Up ( )
Print/fill in clear letters or emboss card:
Insured Name
ID. Card No. Sex Age Y
Policy Holder Policy No
Expiry Date / /
Class
Approval
To be completed by the Dentist:
Duration of Illness: ____ (Days)
Chief Complaint & Main Symptoms:
Significant Signs:
Diagnoses (ICD10)
Primary
Secondary
Other Conditions
Please tick ( √ ) where appropriate:
Regular Dental Treatment ( )
Dental Cleaning ( )
Trauma Treatment Specify: RTA ( ) Work
Related ( ) Other
How:
When:
Where:

Specify the recommended procedures using the tooth number as shown on the teeth map above:
<table><tr><td>Code</td><td>Dental Service</td><td>Tooth No.</td><td>Cost</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td>Total</td><td></td></tr></table>
Providers Approval/Coding Staff must review/code the recommended service(s) and allocate cost and complete the following:
Completed/Coded By
Signature :
Date
/ /
<table><tr><td>Medication Name (Generic Name)</td><td>Type</td><td>Quantity</td></tr><tr><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td></tr></table>
I hereby certify that ALL information mentioned are correct and that the medical services shown on this form were medically indicated and necessary for the management of this case.
Dentist
Signature
Stamp
Date

/ /
I hereby certify that ALL statements and information provided concerning patient identification and the present illness or injury are TRUE.
Name and relationship (if guardian):
Signature (*)
Date ____ / ____ / ____
For Insurance Company Use Only:
Approved ( )
Not Approved ( )
Approval No:
Approval Validity :
Days
Comments (include approved days/services if different from the requested)
Approved /Disapproved By
Signature
Date
/ /
(*) This is applicable only in case of manual DCAF