DENTAL & MEDICAL Insurance Patient's Appointment Summary and billing submission

DENTAL & MEDICAL Insurance Patient's Appointment Summary and billing submission

After submission of this appointment summary form, the submitting Provider authorizes Dental Claims Cleanup to manage the claim submission, communication with the patient and with the insurance regarding this patient's services and insurance claims. Provider attests that the patient authorized the Provider and the Provider's third party claim administrator to act on their behalf to manage insurance reimbursement for patient's services.

Dental Claims Cleanup

1810 Erie Blvd, Syracuse, NY 13210

800-652-3431

Patient Registration

Date*

Date of Service*

Patient's First and Last Name*

Patient's Phone Number*

DOB*

Patient's email*

Patient's Address*

Subscriber Name*

Subscriber Address*

Relationship to Patient*

File Upload*

Attach supporting documentation

clinical notes including the exam/diagnosis date. We will always send the claims for the exam visit.
ledger showing the transactions and your fees
xrays
anesthesia record
referrals from other providers
medical and dental insurance card front and back

Drag and drop files here or

Submitting Provider's Information

Patient Questionaire

What is your chief complaint?

What brings you in today?

Prior treatment

What services, procedures, treatment if any was provided for this condition in the past?

What worked and did not work for this condition

Describe what worked and what did not work for this condition resulting in the patient seeking further treatment or providing medical necessity to proceed with alternative treatment.

For how long has this condition been present?

EXAM-by Provider

Medical Necessity*

What condition type is being treated?

Select or enter value

EXAM Clinical Notes

Clinical Notes

Provider DIAGNOSIS

ICD-10 Frequently Used Diagnostic Codes

Present diagnosis-please select or type in

Select or enter value

Vascular or Neural Diagnostic Codes

Diagnostic codes to treat vascular lesions or conditions

Select or enter value

X-RAYS Diagnosis

Diagnostic codes to treat bones and teeth

Select or enter value

Trauma Surgery Diagnostic COdes

Select or enter value

Soft Tissue Surgery Diagnostic Codes

Select or enter value

Hard Tissue Surgery & Joints Diagnostic Codes

Select or enter value

Dysfunction Diagnostic Codes

Select or enter value

Sleep Diagnostic Codes

Select or enter value

Infection and Pain Diagnostic Codes

Select or enter value

Completed Services-ADA codes

Select or enter value

CPT procedure codes-completed

What procedures did you complete?

Select or enter value

What procedures are you treatment planning?

Provide your fees for procedures performed

Claim Preauth Needed

Select or enter value

PLAN

List the proposed treatment plan and prices

Description of Treatment Goals

What is the goal of treatment

Select or enter value

Scheduled Appointment Date

How much does the patient need to pay today?

Select or enter value

Pay link for todays visit

http://dentalbill.app

Provider's First and Last Name

Provider's Address

Provider's NPI

Provider's EIN

Provider's Email

Provider's Phone Number

provider's email address

Send me a copy of my responses

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