Dental Claim Form Template for United Arab Emirates

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Dental Claim Form

I need a comprehensive Dental Claim Form for my Dubai-based dental clinic that handles both routine and specialized procedures, with sections for multiple insurance providers and electronic submission capabilities, compliant with DHA regulations for implementation by March 2025.

Document background

The Dental Claim Form is a critical document within the UAE's healthcare system, designed to facilitate the processing of dental treatment claims between healthcare providers and insurance companies. This standardized form must be submitted whenever a patient seeks reimbursement or direct billing for dental procedures covered under their insurance policy. The document complies with UAE federal healthcare regulations, including Federal Law No. 2 of 2019 regarding health data protection, and specific emirate-level requirements set by authorities such as the Dubai Health Authority (DHA) and Health Authority Abu Dhabi (HAAD). The form captures comprehensive information about the treatment provided, patient details, insurance coverage, and provider credentials, ensuring efficient processing while maintaining compliance with local healthcare and insurance regulations.

Suggested Sections

1. Patient Information: Basic details including name, Emirates ID, date of birth, gender, contact information, and insurance policy details

2. Primary Insurance Information: Details of the primary insurance policy, including policy number, insurance company name, and policyholder information if different from patient

3. Dental Provider Information: Treating dentist's details, facility information, UAE medical license number, and contact information

4. Treatment Details: Specific information about dental procedures performed, including treatment dates, tooth numbers, procedure codes, and charges

5. Payment Information: Details about the claim amount, any deductibles or co-payments, and preferred payment method

6. Declarations and Signatures: Required signatures from patient/guardian and treating dentist, including declarations of truth and authorization for information release

Optional Sections

1. Secondary Insurance Information: Required when patient has multiple insurance coverage or coordination of benefits

2. Emergency Treatment Declaration: To be included when treatment was provided on an emergency basis without pre-approval

3. Third-Party Payment Authorization: Required when payment is to be made to someone other than the policyholder or healthcare provider

4. Accident Details: To be included when dental treatment is related to an accident or injury

5. Pre-Treatment Estimate: Optional section for pre-treatment cost estimates and approval requests

Suggested Schedules

1. Treatment Codes Reference: List of standardized dental procedure codes accepted by UAE insurance companies

2. Required Documentation Checklist: List of required supporting documents based on treatment type

3. X-Ray and Image Requirements: Guidelines for submitting dental X-rays and other imaging documentation

4. Fee Schedule: Standard fee schedule for common dental procedures as per UAE insurance guidelines

5. Instructions for Form Completion: Detailed guidelines on how to complete each section of the form correctly

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Dental Services

Insurance

Healthcare Administration

Regulatory Compliance

Medical Claims Processing

Healthcare Technology

Financial Services

Relevant Teams

Claims Processing

Insurance Verification

Medical Records

Patient Accounts

Compliance

Healthcare Administration

Finance

Customer Service

Quality Assurance

Operations

Relevant Roles

Dental Insurance Coordinator

Claims Processing Specialist

Healthcare Administrator

Dental Practice Manager

Insurance Verification Specialist

Compliance Officer

Medical Records Coordinator

Dental Office Manager

Insurance Claims Adjuster

Healthcare Finance Manager

Patient Relations Coordinator

Dental Treatment Coordinator

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Authors

Alex Denne

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