Page 18 - GDP - Provider Reimbursement Guide 2022
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Date:
Patient Name: Subscriber Name:
Dentist Name: Dentist License #:
Specialty Type (check one):
Endodontics Oral Surgery Orthodontics Periodontics
Member Waiver Form for Specialty Treatment
Subscriber SSN:
Dentist NPI #:
As a member of Golden Dental Plans, Inc., I understand that I am offered the option to be referred to and to be seen by a licensed In-Network Specialist for my dental treatment. Instead I have chosen to waive this option and allow services to be provided by the above named general dentist. My co-payment amount will be based on the Specialty coverage on my dental plan.
Patient or Responsible Party Signature
Date Signed
Dental Facility Instructions:
Form must be filled out correctly, completely and signed by the patient or responsible party to avoid any delay in processing claims. Send this original to Golden Dental Plans, Inc. along with the dental claim form. Retain a copy for your records.
29377 Hoover Road • Warren, MI 48093 Phone: 1-800-451-5918 • Fax: 586-573-8720 www.goldendentalplans.com
Revised: 05/10/2021
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