HSB Dental Claim Form 2010 - El Paso - HealthSCOPE Benefits

CLAIM FILING INSTRUCTIONSAny person who, with intent to defraud or knowing that he or she is facilitating a fraudagainst a benefits plan, submits an application or files a claim containing a false or deceptivestatement, is guilty of health care fraud.Help us to reduce health care costs by reporting health care fraud. Call 1-800-333-4585.TO THE MEMBER/EMPLOYEE:Complete all items in Blocks 1 thru 15 so that eligibility of the patient can be properlydetermined. (The Member/Employee’s or Authorized Person’s signature and the datesigned are required in the Release Authorization Section). After you complete the PatientSection, give the form to your dentist to fill out.If you have any questions about claims filing, call the Customer Service number onyour ID Card.TO THE DENTIST:Complete all items in Blocks 16 thru 31. (The Internal Revenue Service requires weidentify, record and report payments received from HealthSCOPE Benefits, Inc. Tocomply with this requirement, please furnish your Federal Tax Identification Number.)Mail completed claim forms to:HealthSCOPE BenefitsP. O. Box 610409Dallas, TX 75261