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Southland National Dental Claim Form

Southland National Dental Claim Form

 

INSTRUCTIONS: SOUTHLAND DENTAL CLAIM FORM
 
Alabama public employees who have dental insurance from Southland Benefit Solutions use the dental claim form discussed in this article after having a dental appointment. This document can be obtained from the website maintained by Southland Benefit.
 
Southland Dental Claim Form Step 1: In box 1, check all applicable boxes concerning the type of transaction this claim covers.
 
Southland Dental Claim Form Step 2: In box 2, enter the predetermination/preauthorization number if applicable.
 
Southland Dental Claim Form Step 3: In box 3, give the name, address, city, state and zip code of your insurance company or dental benefit plan.
 
Southland Dental Claim Form Step 4: Indicate with a checkmark in box 4 whether you have other dental or medical coverage. If no, skip to box 12.
 
Southland Dental Claim Form Step 5: If you have other medical or dental coverage, give the name of policyholder or subscriber in box 5, enter their date of birth in box 6, check the box next to their gender in box 7, give their policy or subscriber ID in box 8, the plan or group number in box 9, indicate the patient's relationship to the policyholder in box 10 with a checkmark,  and give the company or benefit plan's name, address, city state and zip code in box 11.
 
Southland Dental Claim Form Step 6: In box 12, enter the policyholder or subscriber name, street address, city, state and zip code for the policy listed in box 3.
 
Southland Dental Claim Form Step 7: In box 13, give their date of birth.
 
Southland Dental Claim Form Step 8: In box 14, indicate their gender with a checkmark.
 
Southland Dental Claim Form Step 9: In box 15, give their policy or subscription identification number.
 
Southland Dental Claim Form Step 10: In box 16, give the plan or group number.
 
Southland Dental Claim Form Step 11: Give the employer name in box 17.
 
Southland Dental Claim Form Step 12: Provide all information requested about the patient in boxes 18 through 23.
 
Southland Dental Claim Form Step 13: Boxes 24 through 35 should be filled out by the office which performed the services in question.
 
Southland Dental Claim Form Step 14: The patient or guardian, as well as the subscriber, should sign and date the left hand bottom corner of the page where indicated.
 

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