Dental Claim Form

1. Ll Denlists p.e-treatrnent estimate Specialty PHD Prior Authoriation # 3. Carrioa Name EDentbtsstatmentofactud$Nis Ll Modicai Claim

CignaDental
4.carierAddr6 P.O. BOX 188037
5.Crv
0. Stato

I eesor

TN

7.Zip

37422
1 1. Slate

8. Patient Name (Last, FjBt, N,lirjdlo)

F

L Addre$

10. City

Drozdowski. Alicia
12. Date ot El&lh(tltWDO/YYm 13. P.6ent lD f

z U
F q

HollowDr. _11415 Whisperinq

1,4. Ser '15.Phono Number

TAMPA
16. ZpCodr

FI

04t 18/ 1956

17. Relaliomhip to SubgcriboriEmptoy@:

DR0026

[u

[r
Name

(81 3)855-1 125

1E. EnploFr/School Addr6

33635

fiser fispou* fiolroIom'

19. Subs./Emp. lD#/SSl*
20. Employer Name

21. Group#

31. ls Patientcoveredby anotherplan

32. Policl! {

115-68-1218
22. Subscribo/Employee Name (Lasl, Fint, iiddl)

3333680/HF

U U o
a. E

Drozdowski, Alicia .
23. Addr$ 24. Phone Numbot

o u o :i

ENo(skip32-37)
33. Other Subscribet's Name

[vm:fioenraror fiueoier

11415Whisoerino HollowDr
2s. crty

(81 3)855-1 125

I t.*
27. Zp Cade

o tr U o
F

34.DatootBidh0frtiDorYYm

t
37. Employe/Sch@l Namo

lOS.Ser

| 3o.phnnrognmName

lO*8,
Addr6

tu e, uJ
@ d

JAMPA
2E.DateofBirttr(lvir/DD/YYYY)

I
lA.UarilotStarr

33635
I gO.S",

36. Sub6cribrEmployee Status Iempoyea EParr-tmestatF EFuI-timestudont Dpart-timestudont

()
o
@ f

0a / tg

I tgta

flsi"sru , [lr,r""iuo [or*

| Eu Eo

v,

39. I ha beon intomed of th treabhenl plan and Miatod fees. I agree lo b res@nsbls loa 6ll darg6 ror oonht sMces and matgrials not pil by mydental benefitplan, untes tfie healing practicehas.acontractuat dntjslor dential agiementwith my plan proiriOldng at oi i podion6t sch uo"n, *mf,d under apptiebte taw, I authodzo,eteaseot;ny Intormation retating ili,l*Ti",lo.u

,10.Employer/school Name
Add16

benefbotheMis pyabt. to m dkcdy to thc 11;-Ll1_..ry-:9q9" ?-.:.snt ot thodsnrat Etwnams oentat onny.

ON F|LE x SISNATURE
tbned (Pslionvcuardien) 42. N.me of Billing Donlist or Dontal Ehtty

06/2712013
D.t6 0tti,VDD/yyyn 43. Phone Numbr

ON F|LE x S|GNATURE
Signed (Employeelsubscribr) 44. Proviler lD*

06/2712013
Date (MtvlDo/yyyy) 45. DonGt S@. Sec. orT.l.N.

Phillip J GoffD.D.S.
F

(727\845-7353
4T.DenGtLjconse#

tr 2
o o z o
IIJ

46- Addres

|
| 4S.FiFtvisitdaleotcurrqnt

431970131
49. Place oftrealhent

t620 Sterlins La
so.crty

DN0011904
lsr.s"te

|
fi Ho

$il*:

Som* [no"p. fiecr flomt

54. b troatnent for othodontiG? lf *M6 alreadycommoncd: Oate spplhmG dacad !V* S No

PortRichev
55. lf prGtleis(dM, hi[at ptacement? bridgo, d6ntu.s), b tis [ V* [ ruo

pr-

lsz.z:pcoa"

53. RadiogEphsor modetsencl6d? [Ye, xo*manp_ Oiiu of pri* plu""r"nt

| caass
Ve"

tf rc, .os$n for .ept@ment

To0alm6. ottodtnnt romaining

56.b boalment rqlt ot @pstimat i[n6 or inju.f Brietd@riplionanddat6a

K NoI

57. ls troatrnent resultof: Brief de$ripdon ard dat6

auroauittenft Qoterraitenn

[tnuitte,

58. Oagncb Code lndex(optionat)

-r:-mo0/i/tDD/YYm

2Too0r
Surfaco

r.--Diagn6is lMer #

l.-P@edure Code

s.otv

o.D@.iplion

z.-F@

8._
Admin. tls6 Only

06 27 20't3 0 27 2013

30 30

)2750 )2950

Crown-porc fusehighnoble mtl pins Crown buildup, includ any

471.00 78.00

t0. ldenlify all mi$ing teeth wih 'X' Penanenl

Pdmary

Total Fs

1 2

3 4

549.00

7 I

3 2 3 13 0 2 s z B 2 7 262s I
6l . Remarks fo. unusml $ryis

9 1 0 1 1 1 2 1 3 1 4 1 l5e1e6c o e

l r O H

r . r

Paymont by oths. d9n Max.Allowable Ooduclible Cafiier % Car.ior Par! Palient PaF

z t z s 2 2 4 , q , 1 s 1 81 7 | r s

n o eTo N M L K

t \

{+ pL}

\\f
:r

s\

x\tf\"t\

\3\\:'

\!Yt \eX\tr

nreoy ce'ry mar mo pr@ures as rffited by.date aro in progr* (for procedure that require murtifi6rsj-i bs6n complet.d and thailhe fees suknitted ars the actrar fgla ihave iha;ged and intend to ;oiloc{ for iho* pr@odur6.

GotrD.D.S. x*_PhillipJ
tjignod Clrealing Ocnlist)

DM011904_
Licen$ #

__ o6tZl&13_
Date (MtWDD/yyyy)

6,(.C'ty

I OS. SUe

Port Richey

I rl

I gaoog

@American DentalAssociation, 1999

Patient Treatment CaseReport

Patlent: Provider: Phone: Office:

Drozdowski, Aficja Phillip J. Goff, D.D.S. (727)845-7353 8620Sterling La PortRichey, FL 34668

Date: 612712013 Chart#: DR0026 SS#: 115-68-1218 Birthdate:411811956

Treatment Plan ' ', Alternate Cases: Gase Name: Status: Comment: Note: Created,

Priority: Last Updated: 10125120'11

Finance Status: None

Fees updated on1012512011 for one or more procedures using the Update Treatment Plan Fees.

EntDate PrcDate

Visit

Tooth

Surface

Code

Prov

Description

Fee

Pat Primlns

Seclns 0.00 0.00 0.00 Seclns 0.00 0.00 0.00 0.00

12t4t201212t4t2012 2 12t4t201212t4t2012 2

29 29

D2750 DDS1 Crown-porc fusehighnoble 471.00 353.25 117.75 mtl D2950 DDS1 Crown buildup, includ any 78.00 23.40 54.60 pins Visit:2 Subtotal: 549.00 376.65 172.35
Surface Code Prov Description

Ent Date Prc Date

Visit

Tooth

Fee

Pat Prim lns

6t27t2013 6t27t2013 3 6t27t2013 6n72013 3

30 30

D2750 DDS1 Crown-porc fusehighnoble 471.00 353.25 117.75 mtl D2950 DDS1 Crown buildup, includ any 78.00 23.40 54.60 pins Visit:3 Subtotal: 54s.001376.65 )172.35 Total: 1,098.00 >5J-36.- g44.7o
Trea$nent lrlalrTotal Estimated Deductible to be Applied Estimated Insurance Payment Estimated Patient's Portion PatientBalance FamilyBalance 1,098.

0 34/.. 753 0 0

/#.:t

DentalInsurance Benefits AnnualPlanBenefits PaidBenefits YTD Pending Insurance Est.YTD Est.BenefitsRemaining YTD BenefitsExpire Deductible OwedYTD

Patient Primary Secondary

750.00 0.00 0.00 750.00

Standard
Preventive Other

12131!g\alQ

0.00 0.00

0.00

PrimaryDentalInsurance Secondary DentalInsurance

Cigna Dental

* Recommended Case

*--*#

IF'-#
7 J ,

Page:1 of 1

IERI{IIICL I. D.! ffRll|Aill$l

!IJN

0?5000 88589900057091

i'fl]lrft*ililf*1141 SALE Entc||r 00194i I JUL OATE ?I, 13 Rnilr 19470015

Ill{,0lcE! 05??74 Illf! 0ir08 AIJT|| ll0! 17?,q?4

TOTAL

$134.15

ALICJA DRO2OOI,IS|(I ctl$t0t'ttR coP1|

PHILi-li u0fF PR 9936 i{i,i! it iloRrll PORI RIC}|I!, FL34668 IERI{II.IfiL I,D.t l'rtf,[t|Al,ri $l lnSrERIAn0 **f**#t$t*90!' SALE EAICl|T 001!31 Oriitr ilili ' RFlll 19300ir

0?5009 8t58000005/001

"'l ill|flli. ,-r(irr T r; : g;; g'i A[|i.iiii: ii?1.138

$26S.60

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