Download Request For Authorization And Benefits For Orthodontic Treatment

United Food & Commercial Workers Unions
and Food Employers Benefit Fund
Request For Authorization And
Benefits For Orthodontic Treatment
6425 Katella Avenue, Cypress, CA 90630-5238
P.O. Box 6010, Cypress, CA 90630-0010
714-220-2297 • 562-408-2715 • 877-284-2320
www.scufcwfunds.com
Patient’s Last Name
This Claim is for:
Self
Child
Patient’s First Name
PARTICIPANT INFORMATION
Date of Birth (mm/dd/yyyy)
Male
Female
Spouse
Supply all information requested below.
Last Name
First Name
Mid. Initial
Social Security Number
Mailing Address
Street:
City
State
ZIP code
Home phone (
)
Employer
Work phone (
(
)
Yes
City
State
ZIP Code
Name of Primary Insured
Name of Other Plan
No
Other Plan’s Mailing Address
Street:
SPOUSE/DOMESTIC PARTNER’S INFORMATION
Last Name
Email Address
Employer’s Address
Street:
Is the patient covered under another orthodontic plan
If “Yes,” you must provide the information below.
Other Plan’s phone
)
Date of Birth (mm/dd/yyyy)
City
State
ZIP code
Supply all information requested below.
First Name
Mid. Initial
Social Security Number
I hereby certify the statements hereon and those attached are true and correct to the best of my knowledge and I authorize any physician, surgeon, practitioner or other person, any
hospital, including veterans administration or governmental hospital, any medical service organization, any insurance company, or other institution or organization, to release to each
other any medical or other information acquired, including benefits paid or payable, concerning this or other disabilities. A photostat of this authorization shall be as valid as the original.
I understand that it is fraudulent to fill out this form with information I know to be false or to omit important facts, and that criminal and/or civil penalties can result from such acts.
______________________________________________________________________
Participantʼs Signature
Date
______________________________________________________________________
Spouse/Domestic
Date
Partnerʼs Signature
I hereby authorize payments directly to the provider named below for services of the benefits otherwise payable to me under the terms and conditions of the Benefit Fund. I understand
I am financially responsible to the provider for charges not covered by the Fund.
______________________________________________________________________
Participantʼs Signature
Date
______________________________________________________________________
Spouse/Domestic
Date
Partnerʼs Signature
Orthodontic Treatment And Charges To be Completed By Orthodontist. Prior Approval Required On All Treatment Plans.
1.
2.
3.
Date of first visit (current series)_______________________
Date of Appliance Placement______________________
Phase:
☐ Full
☐ Phase I
☐ Phase II
Diagnosis, Treatment Mechanics and treatment plan (to include type of appliance and retainers.) Attach additional sheet if necessary.
4.
5.
SET OF INTRAORAL PHOTOGRAPHS AND X-RAYS MUST ACCOMPANY CLAIM FORM.
Cost of Diagnostic Records,
Date of Service:___________________
Charges: $_________________
Study Models and X-Rays (ADA Code 08999)
Total orthodontic fee, exclusive of case analysis:
Charges: $_________________
Are you an Orthodontic Specialist?
☐ Yes ☐ No
Member of______________________________Orthodontic Society
6.
7.
ORTHODONTIST INFORMATION
Corporation Name
Mailing Address
Street:
Orthodontist’s Signature
Supply all information requested below.
Orthodontist’s Name
Tax I.D. Number
City
State
ZIP code
Office phone
(
)
Date
WHITE & YELLOW - Fund Office
PINK - Orthodontist
FM CL BR01 0411