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Fillable Nyc Pba 14 Form in PDF

The Nyc PBA 14 form is a dental claim form used by members of the Patrolmen’s Benevolent Association in New York City. This form facilitates the submission of dental claims for reimbursement from the PBA funds office. Proper completion of the form is essential to ensure timely processing and payment for dental services received.

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Article Guide

The NYC PBA 14 form serves as a crucial tool for members of the Patrolmen’s Benevolent Association seeking dental benefits. This form facilitates the submission of dental claims, ensuring that members receive appropriate reimbursements for dental services rendered. It requires essential information, such as the member's social security number, name, and contact details, as well as specifics about the patient, including their relationship to the member and date of birth. The form also prompts members to disclose any additional health or dental coverage, which is vital for coordinating benefits. A signature from the member is mandatory, underscoring the importance of accuracy and accountability in the claims process. Additionally, the form outlines requirements for precertification for certain procedures, such as crowns and orthodontics, highlighting the need for members to communicate effectively with their dental providers. By following the instructions provided, members can navigate the claims process smoothly and ensure that they receive the benefits they are entitled to.

Preview - Nyc Pba 14 Form

		DENTAL CLAIM FORM
PATROLMEN ’S
	BENEVOLENT	NYC PBA FUNDS OFFICE
	ASSOCIATION	NYC PBA FUNDS OFFICE
	ASSOCIATION	125 Broad Street, 11th Floor New York, N.Y. 10004
	Of The City Of New York, Incorporated	212-349-7560
	Of The City Of New York, Incorporated

		PLEASE PRINT - SEE REVERSE SIDE BEFORE COMPLETION

MEMBER COMPLETES

MEMBER’S SOCIAL SECURITY NO.

2. MEMBER’S NAME (LAST, FIRST, MIDDLE INITIAL)

MEMBER’S ADDRESS (NUMBER, STREET)

CITY

STATE

ZIP CODE

PATIENT’S FIRST NAME

5. PATIENT’S LAST NAME

6. PATIENT’S RELATIONSHIP TO MEMBER

7. PATIENT’S DATE OF BIRTH

SELF SPOUSE DGHTR SON STEP-CHILD OTHER*

DOES PATIENT HAVE OTHER HEALTH AND/OR DENTAL COVERAGE

YES. IF YES, PLEASE GIVE THE FOLLOWING:

POLICY HOLDER’S NAME

SOCIAL SECURITY NO.

NAME AND ADDRESS OF EMPLOYER/UNION

NAME OF INSURANCE CARRIER

MEMBER’S SIGNATURE IS REQUIRED ON ALL CLAIM FORMS, SIGNATURE OF SPOUSE OR PHOTOCOPY OF MEMBER’S SIGNATURE IS NOT ACCEPTABLE.

I HEREBY CERTIFY THAT ALL SERVICES LISTED BELOW WITH A DATE OF SERVICE HAS BEEN DONE AND/OR REQUEST PRE-CERTIFICATE FOR TREATMENT PLAN LISTED WITHOUT DATES OF SERVICE.

PLEASE MAKE REIMBURSEMENT

ACTIVE

PAYABLE TO

MEMBER

DENTIST

SIGNATURE OF MEMBER

DATE

RETIRED

10. DENTIST NAME

13. PHONE NO.

MEMBER’S HOME PHONE

(

)

(

)

11. DENTIST ADDRESS

NUMBER AND STREET

14. PRACTICE

GENERAL

PERIO

ORTHO

ENDO

ORAL SURGERY

PROSTHO

PEDOD

12. CITY

STATE

ZIP CODE

DENTIST TAX IDENT. NO.

TAX

S.S.

DENTIST

EXAMINATION AND TREATMENT RECORD — USE CHARTING SYSTEM SHOWN

TOOTH

DESCRIPTION OF SERVICE (INCLUDING X-RAYS

DATE SERVICE

PROCEDURE

FUND USE

INDICATE MISSING

SURFACE

PERFORMED

FEE

PROPHYLAXIS, MATERIALS USED ETC.)

CODE

ONLY

TEETH WITH AN X

LETTER

MO. DAY. YR.

COMPLETES		PRINT
COMPLETES			LINE
			LINE
DENTIST	PLEASEPROCEDURE
	ONE	PER

	15. ARE X-RAYS ENCLOSED
	YES
	NO
	IF YES, HOW MANY?

16. IF PROSTHESIS, IS THIS

17. IF NO, REASON FOR

18. DATE OF PRIOR PLACEMENT

TOTAL

THE INITIAL PLACEMENT

REPLACEMENT

FEE

YES

CHARGE

19. I CERTIFY THAT THE PROCEDURES INDICATED WILL BE OR HAVE BEEN COMPLETED

TOTAL BENEFIT

C.O.B.

SIGNED (DENTIST)

DATE

FOR

EXAM

AUDIT

CODE

X-RAY

DENTIST PROFILE

REMARKS

OFFICE

USE

PBA-14 (Rev. 2/03)

(SEE OTHER SIDE )

INSTRUCTIONS

PRECERTIFICATION IS REQUIRED FOR ALL CROWN AND BRIDGE, PROSTHETIC, ORTHODONTIC, AND PERIODONTIC WORK.

DENTIST:X-RAYS MUST BE SUBMITTED WITH ALL CLAIMS REQUESTING PRECERTIFICATION.

STUDY MODELS ARE ALSO REQUIRED FOR ALL

ORTHODONTIC CLAIMS.

PERIO CHARTING IS REQUIRED FOR ALL

PERIODONTIC CLAIMS

MEMBER:DO NOT ALLOW YOUR DENTIST TO COMMENCE ANY PROCEDURES WHERE PRECERTIFICATION IS REQUIRED UNTIL BOTH YOU AND YOUR DENTIST HAVE RECEIVED THE PRECERTIFICATION.OTHERWISE, YOU WILL BE LIABLE FOR PAYMENT OF SERVICES THAT MIGHT NOT BE APPROVED BY THE PLAN.

NOTE:ALL COMMUNICATIONS WITH THE FUNDS OFFICE MUST INCLUDE PATIENTS CLAIM NUMBER (WHEN KNOWN) OR MEMBERS SOCIAL SECURITY NUMBER.

IMPORTANT: FOR PROTECTION OF YOURSELF AND THE PBA FUNDS, PLEASE DO NOT SIGN BOX #9 ON THE FRONT OF THIS FORM UNTIL THOSE SERVICES ACTUALLY ARE PERFORMED OR THOSE REQUIRING PRECERTIFICATION HAVE BEEN FILLED-IN BY THE DENTIST.

ALL CLAIMS SUBJECT TO REVIEW FOR COORDINATION OF BENEFITS

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Form Characteristics

Fact Name	Description
Form Purpose	The NYC PBA 14 form is a Dental Claim Form used by members of the Patrolmen's Benevolent Association to request reimbursement for dental services.
Member Information	Members must provide their Social Security number, name, and address on the form to ensure proper identification and processing of claims.
Patient Details	The form requires information about the patient, including their name, relationship to the member, and date of birth.
Other Coverage	If the patient has other health or dental insurance, details about the policy holder and insurance carrier must be included.
Signature Requirement	The member's signature is necessary on the claim form. A spouse's signature or a photocopy of the member's signature is not acceptable.
Dental Provider Information	Details about the dentist, including their name, address, and phone number, are required to process the claim effectively.
X-Ray Submission	X-rays must be submitted with all claims that request precertification, ensuring that all necessary documentation is provided.
Precertification Requirement	Precertification is mandatory for specific dental procedures, such as crowns and orthodontics, to avoid unexpected costs for the member.
Communication	All communications with the PBA Funds Office should include the patient's claim number or the member's Social Security number for efficient processing.

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