Any updates to these instructions will be posted on the ADA’s web site ( Member Forms, Provider Forms, and Broker Forms. ** The Pre-Paid dental plan refers to (a) DHMO's which are underwritten by Managed Dental Care of California or Managed DentalGuard or; (b) Managed DentalGuard plans underwritten by The Guardian Life Insurance Company of America. About Us. Network Specialist: Only the covered services referred by the PCD and listed on this form will be considered for payment. Please consult your Plan Administrator for the plan available to you. authorization has been obtained from the Plan. Dental Claim Form 1. Site Map: Home. Our Dentists Type of Transaction (Check all applicable boxes) ... guardian, or other individual as appropriate under state law and the circumstances of the case. Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. Our Clinics. Subscriber Signature: Necessary when the patient/insured and dentist wish to have benefits paid … You may request Extraction Form. Guardian Dental Insurance Exchange - Documents and Forms for download. 37. All necessary diagnostic x-rays must be attached and sent to the network specialist. The following information highlights certain form completion instructions. Medical and Dental Information Update. Dental Claim Form Guardian Group Dental Claims PO Box 2459 Spokane WA 99210-2459 . Please have the member sign and date all Specialty Referral Request Forms.


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