11. Employee First Name
To Be Completed by Employee
Dental Expense Claim Form
1. Patient First Name
Middle Initial
Last
2. Relationship to Employee
3. Sex
4. Married?
5. Patient Date of BirthMo. / Day / Year
6. For Office Use
7. If Full-Time Student  (Age 19 or Over)
School
City
State
8. EMPLOYEE ID Number
9. If Disabled(Age 19 or Over)
10. Name of Group Dental Program
Middle
Last
12. Employee Date of Birth
13. Office Phone (Area Code)
14. Employee Residence Mailing Address
15. City, State, Zip
16. Are other Family Members Employed?
Name of other Employed
His/her ID Number
17. Date of Birth
18. Name and Address of Employer for Item 16
19. Is Patient Covered by Another Dental Plan?
If Yes, complete the following:
Dental Plan Name
Group No.
Name and Address of Carrier
20. I Authorize Release of any Information Relating to this Claim.
Date
21. I Certify that the Above Information is Correct.
22. I Authorize Payment Directly to the Below-Named Dentist.
x
x
Date
(Signature of Patient or Signature of Authorized Representative if Minor)
Employee Signature
x
Date
Dentist's Office Name
Dentist's Provider # (ask your dentist)
Submit this form to HR. Click Submit when the above is complete.
 In addition - Print this Form, fill out the bottom portion and Fax to 999999999.  Your signature is required!
The Flow of Information does not need to be 'one way'.  The example below shows how personalized information can be received from an employee via the web or intranet for the beginning of Self Administered Claims approval.
Each 'data field' (Patient First Name, etc.) would be a Column in a Table.  When the Form was submitted, the following Steps would occur:
As the employee was filling out the Form, information would be getting temporarily 'stored' in their browser (Javascript). Look at Item 2 (Relationship to Employee). In this case - and also the other Radio buttons, a Value would be assigned.  So 'Self' may be a 1, 'Spouse a '2' ... and so one.  For Item 10 (Group Dental Program), an integer would also be assigned -- that would match your current HRIS.We used our WYSIWYG Application
Editor to draw the Form, but it could have been even easier:
If available as a paper form:1) Scan the form2) Give us the scanned image3) We would use the image as a background - then add the form elements.  We'd be done in ~ 5 hours (including the Table), probably less.
 Watch a Movie
 Below is a sample. Submit will not occur.