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Download Cigna Dental Claim Form (Form 590154f). This is a claim form for Cigna Dental. Only complete this form if your dentists office does not file your claim for you. If you are completing this form, be certain to complete all required information needed and read all of the provided information at the end of the form.

How To Write

Step 1 – Section 1 – Header Information

  • 1. Type of Transaction (check all boxes that apply)
  • 2. Predetermined/Preauthorization Number

Step 2 – Section 3 – Insurance Company/Dental Benefit Plan Information –

  • 3. Company/Plan Name, Address, City, State, Zip Code

Step 3 – Section 4 – Other Coverage – If There is No Other Coverage, Leave This Section Blank –

  • 4. Dental?
  • Medical?
  • 5. Name of Policyholder/Subscriber Last Name, First Name, Middle Initial, Suffix ie: Dr., Jr. Esq. etc.
  • 6. Date of Birth (mm/dd/yyyy
  • 7. Gender (check one)
  • 8. Policyholder/Subscriber ID (SSN or ID Number)
  • 9. Plan/Group Number
  • 10. Patient’s Relationship to Person Named in Number 5.
  • 11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code

Step 4 – Section 12 – Policyholder/SAubscriber Information ( for insurance named in Number 3.)

  • 13. Date of Birth mm/dd/yyyy
  • 14. Gender (check one)
  • 15. Policyholder/Subscriber ID (SSN or ID Number)
  • 16. Plan Group Number
  • 17. Employer Name

Step 5 – Section 18 – Patient Information

  • 18.Relationship to Policyholder/Subscriber In Number 12 Above (check one)
  • 19. RESERVED FOR FUTURE USE – Leave Blank
  • 20.Last, First, Middle Initial, Suffix ie: Dr., Jr., Esq. etc. – Address, City, State. Zip Code
  • 21. Date of Birth mm/dd/yyyy
  • 22. Gender (check one)
  • 23. Patient ID/Account Number That has Been Assigned by the Dentist

Step 6 – Record Of Services – This is to be completed by the Dentist and His Staff- Do not mark in this area –

Step 7 – Section 36 – Authorizations –

  • 36. Read the information as stated in box 36. – If you understand and agree -
  • Patient/Guardian Signature
  • Date mm/dd/yyyy
  • 37. Read the statement above the signature line, if you understand and agree -
  • Subscriber’s Signature
  • Date mm/dd/yyyy

Step 8 – Section 38 – Ancillary Claim/Treatment Information

  • 38. Place of Treatement (check one)
  • 39. Enclosures (Y or N)
  • 40. Is Treatment Orthodonics? (check one)
  • 41. Date Appliance Place mm/dd/yyyy
  • 42. Months of Treatment
  • 43. Replacement of Prosthesis(check one)
  • 44. Date of Prior Prosthesis mm/dd.yyyy
  • 45.Treatment Resulting From (check one)
  • 46. Date of Accident mm/dd/yyyy

Step 9 – Section 48 – Leave Blank If Dentist or Dental Entity Is Not Submitting Claim On Behalf of the Patient or Insured/Subscriber – Otherwise, complete –

  • 48. Name, Address, City, State, Zip
  • 49. NPI
  • 50. License Number
  • 51. SSN or TIN
  • 52. Phone Number
  • 52 a. Additional Provider ID

Step 10 - Section 53. - Treating Dentist And Treatment Location Information – This section is only to be completed by the treating Dentist Only.

Other attached sheets are for your information.

 

 

 

 

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