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Dental Claim Forms Library - United Concordia Dental

Dental Claim Forms Library

Claim Forms

These are forms your dentist will complete to submit a claim to United Concordia Dental. You should only need one if you are visiting a non-network dentist; our network dentists will file claims for you.

Standard Claim Form PDF    (How to use claim form) PDF
Bring this claim form to appointments with a non-network dentist.

AZ Standard Claim Form PDF    (How to use claim form) PDF
(Arizona residents only) Bring this claim form to appointments with a non-network dentist.

NY Standard Claim Form PDF    (How to use claim form) PDF
(New York residents only) Bring this claim form to appointments with a non-network dentist.

 

Dentist Advisor Guidelines

The Dentist Advisor Guidelines PDF are a set of clinical guidelines applied during claim review. The clinical guidelines are detailed by procedure type.

 

Referral Forms

DHMO general dentists use these forms to refer you to a specialist for specialty care.

Specialty Referral Claim Form PDF
Bring this to your general dentist to receive a referral to a specialist.

AZ Specialty Referral Claim Form PDF
(Arizona residents only) Bring this to your general dentist to receive a referral to a specialist.

CA Specialty Referral Claim Form PDF
(California residents only) Bring this to your general dentist to receive a referral to a specialist.

MD Uniform Dental Consultation Referral Form PDF
(Maryland residents only) Bring this to your general dentist to receive a referral to a specialist.

 

Nominate Your Dentist

Use this form if you are currently visiting a non-network dentist but would like United Concordia Dental to consider that dentist for participation in our networks.

Nominate Your Dentist
Complete this online form and select Submit to nominate your dentist for participation in our networks.


Dependent Certification

Use this form to certify that your dependent is a student or disabled, so he/she can continue to be covered on your plan beyond the date when dependents are no longer eligible. A form will be mailed to you prior to the dependent end date, and every year of extended coverage.

Dependent Certification form PDF
Complete and return this form to the address on the front of the form.

 

Patient Privacy Information

Use this form to grant United Concordia Dental permission to share your benefits information with specific people or parties.

Request and Authorization for Disclosure of Health Information PDF
Complete this form and fax or mail to the addresses provided on the last page.

CA Request and Authorization for Disclosure of Health Information PDF
(California Residents Only) Complete this form and fax or mail to the addresses provided on the last page.

 

CA Language-Preference Forms

This form notifies you of your right to language assistance and you can use it to send us the preferred written and spoken language of each member of your family.

California Language Preference Form (DHMO) PDF
(For members with a DHMO plan) Complete the form and mail, email or fax to the addresses provided.

CA Language Preference Form (FFS) PDF
(For members with a FFS plan) Complete the form and mail, email or fax to the addresses provided.

 

CA Grievance & Resolution Form (DHMO)

Use this form to submit a grievance to United Concordia Dental about your DHMO plan.

Grievance Form
Complete this online form and select Mail Form to submit a grievance to United Concordia.

 

Quality of Care Form

Members with concerns regarding the quality of dental treatment; such as but not limited to the quality of cleanings, fillings, root canal treatment, crowns, bridges & dentures, provided by a participating dentist must submit their concerns to the address listed below within 180 days* of identification. You may print and submit our Member Quality of Care Form PDF to:
 

United Concordia Companies, Inc.
Quality Assurance Department
4401 Deer Path Road DP 3B
Harrisburg, PA 17110


*State, federal or contractual requirements may override the Quality Assurance Department filing requirement.


Formularios de Reclamos

Estos son los formularios que su dentista completará para presentar un reclamo a United Concordia Dental. Si usted acude a un dentista fuera de la red, debería solo necesitar uno; nuestros dentistas dentro de la red presentarán todos los reclamos por usted.

Formulario de reclamos convencional PDF    (Cómo utilizar el formulario de reclamo) PDF
Lleve este formulario de reclamo a las citas cuando vaya con un dentista fuera de la red.

Formulario de reclamos convencional (Solo Arizona) PDF 
(Solo residentes de Arizona) Lleve este formulario de reclamo a las citas cuando vaya con un dentista fuera de la red.

Formulario de reclamos convencional (Solo Kentucky) PDF
(Solo residentes de Kentucky) Lleve este formulario de reclamo a las citas cuando vaya con un dentista fuera de la red.

 

Certificación dependientes

Utilice este formulario para certificar que su dependiente es un estudiante o con discapacidad, por lo que él / ella puede continuar a ser cubiertos en su plan más allá de la fecha en que los dependientes ya no son elegibles. Un formulario será enviado por correo antes de la fecha de finalización dependiente, y cada año de cobertura extendida.

formulario de Certificación de Dependiente PDF
Completar y enviar el presente formulario a la dirección en la parte frontal de la forma.

 

Información de Privacidad del Paciente

Use este formulario para otorgar permiso a United Concordia Dental para que comparta la información de sus beneficios con personas o partes específicas.

Pedido y Autorización para la Revelación de Información de Salud PDF
Complete este formulario y envíelo por fax o correo a la dirección que se proporciona en la última página.

Calif Solicitud y Autorización para la Revelación de Información de Salud PDF
(Solo residentes de California) Complete este formulario y envíelo por fax o correo a la dirección que se proporciona en la última página.

  

Formularios de preferencia de idioma para CA

Este formulario le informa de su derecho de obtener asistencia con el idioma y puede utilizarlo para indicarnos el idioma de preferencia, escrito y hablado, de cada uno de los miembros de su familia.

Formulario de preferencia de idioma para California (DHMO) PDF
(Para los miembros con un plan DHMO) Complete el formulario y envíelo por correo, correo electrónico o vía fax a las direcciones proporcionadas.

Formulario de preferencia de idioma para CA (FFS) PDF
(Para los miembros con un plan FFS) Complete el formulario y envíelo por correo, correo electrónico o vía fax a las direcciones proporcionadas.

 

CA Formulario de Presentación de Quejas y Reclamaciones (DHMO)

Use este formulario para presentar una queja a United Concordia Dental acerca de su plan DHMO.

Formulario De Quejas
Complete este formulario en línea y seleccione Formulario por correo (Mande el Formulario) para presentar una queja a United Concordia.