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

 
 
 
 
 
 
 
 
 
 
 

Attach supporting documentation

  1. clinical notes including the exam/diagnosis date. We will always send the claims for the exam visit.
  2. ledger showing the transactions and your fees
  3. xrays
  4. anesthesia record
  5. referrals from other providers
  6. medical and dental insurance card front and back
Drop your files here
 

 

Submitting Provider's Information

 

 

Patient Questionaire

 

What brings you in today?

 

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

 

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.

 
 
 

 

EXAM-by Provider

 

What condition type is being treated?

 

Clinical Notes

 
 

Provider DIAGNOSIS

 

Present diagnosis-please select or type in

 

Diagnostic codes to treat vascular lesions or conditions

 

Diagnostic codes to treat bones and teeth

 
 
 
 
 
 
 
 

What procedures did you complete?

 
 
 
 

 

PLAN

 
 
 

What is the goal of treatment