INSTRUCTIONS: ALABAMA ADA DENTAL CLAIM FORM

Alabama public employees receiving supplemental dental coverage administered by Southland Benefit Solutions can use the claim form discussed in this article. This document can be obtained from the website maintained by Southland Benefit Solutions.

Alabama ADA Dental Claim Form Step 1: In box 1, indicate the kind of transaction being documented with a check mark.

Alabama ADA Dental Claim Form Step 2: In box 2, enter the predetermination or preauthorization number.

Alabama ADA Dental Claim Form Step 3: In box 3, enter your dental benefit plan or insurance company name, address, city, state and zip code.

Alabama ADA Dental Claim Form Step 4: In box 4, indicate whether you have other dental or medical coverage with a check mark. If no, you can skip steps 5 through 11.

Alabama ADA Dental Claim Form Step 5: In box 5, enter the name of the policyholder or subscriber of the other dental or medical coverage.

Alabama ADA Dental Claim Form Step 6: In box 6, enter the date of birth of this policyholder or subscriber.

Alabama ADA Dental Claim Form Step 7: In box 7, indicate this policyholder or subscriber's gender with a check mark.

Alabama ADA Dental Claim Form Step 8: In box 8, enter their policyholder or subscriber ID. This can be either their Social Security number or ID number.

Alabama ADA Dental Claim Form Step 9: In box 9, enter the plan or group number.

Alabama ADA Dental Claim Form Step 10: In box 10, indicate the relationship of the patient to the person named in box 5 with a check mark.

Alabama ADA Dental Claim Form Step 11: In box 11, enter the name, address, city, state and zip code of the other insurance company or dental benefit plan.

Alabama ADA Dental Claim Form Step 12: In box 12, enter the name, address, city, state and zip code of the policyholder or subscriber of the insurance company named in box 3.

Alabama ADA Dental Claim Form Step 13: In box 13, enter this policyholder or subscriber's date of birth.

Alabama ADA Dental Claim Form Step 14: Indicate this policyholder or subscriber's gender with a check mark in box 14.

Alabama ADA Dental Claim Form Step 15: Complete the rest of the form as instructed.