Form United Concordia C United Concordia C Active Duty Dental Program

Claims Processing
P.O. Box 69429
Harrisburg, PA 17106-9429

Active Duty Dental Program

1. Sex

Web site: www.addp-ucci.com

2. Birthdate

mo

day

P
A 3. Active Duty Service Member’s (ADSM) name
middle
last
First
T
I
E 4. Active Duty Service Member's (ADSM) social security no.
N
T 5. Mailing address
q Male

q Female

City, State, Zip
S
E
C
T 6. Telephone number
I
O 7. Rank/Branch of service
N

D
E
N
T
I
S
T

8. Program name

Active Duty Dental Program

9. Appointment Control Number

Authorization Number / Referral Number
10. Email Address
11. I have reviewed the following treatment plan. I authorize release of any information
relating to this claim.

12. Dentist name

13. Dentist soc. sec. or T.I.N.

year

12a. Provider no.
14. Dentist license no.

12b. NPI #

Signature

Date

16. Dentist mailing address -- street address

15. Dentist phone no.

City, State, Zip

Dental Readiness Class: ___________

q (1) ADSM has good oral health and is not expected to require dental treatment or reevaluation for 12 months.
q (2) ADSM has some oral conditions, but you do not expect these conditions to result in dental emergencies within 12 months if not treated (i.e., requires prophylaxis,, asymptomatic caries
with minimal extension into dentin, edentulous areas not requiring immediate prosthetic treatment).

q (3) ADSM has oral conditions that you do expect to result in dental emergencies within 12 months if not treated. Examples of conditions are: (X the applicable block or specify in the space provided)
q (a) Infections: Acute oral infections, pulpal or periapical pathology, chronic oral infections, or other pathologic lesions and lesions requiring biopsy or awaiting biopsy report.
q (b) Caries/Restorations: Dental caries or fractures with moderate or advanced extension into dentin; defective restorations or temporary restorations that patients cannot maintain for
S
12 months.
E
q (c) Missing Teeth: Edentulous areas requiring immediate prosthodontic treatment for adequate mastication, communication, or acceptable esthetics.
C
q (d) Periodontal Conditions: Acute gingivitis or pericoronitis, active moderate to advanced periodontitis, periodontal abscess, progressive mucogingival condition, moderate to heavy
T
subgingival calculus, or periodontal manifestations of systemic disease or hormonal disturbances.
I
q (e) Oral Surgery: Unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs or symptoms of pathosis that are recommended for removal.
O
q (f) Other: Temporomandibular disorders or myofascial pain dysfunction requiring active treatment.
N
17. If you selected Block (3) above, please circle the condition(s) you identified in this ADSM if they appear above, or briefly describe the condition(s) below:

18.

TOOTH
NO. OR
LETTER

SURFACE

DESCRIPTION OF SERVICES
(INCLUDING X-RAYS, PROPHYLAXIS, MATERIALS USED,ETC.)

DATE SERVICE
PERFORMED

MO.

DAY

YR.

PROCEDURE
CODE

20. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing
any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties. The signer agrees that any personally identifiable health information about the signer or
signer's enrolled dependents is protected by the Health Insurance Portability and Accountability Act of 1996 and other privacy laws. In accordance with those
laws, United Concordia may use and disclose Protected Health Information for treatment, payment and health care operations as described in its Notice of Privacy
Practice.
Signature (Dentist)
5579 (04/09)

Date

FEE
CHARGED

19. TOTAL FEE CHARGED