View Insurance Form Printing - page 1, page 2, page 3, page 4 screens. View Video, 0 min. 31 sec.

Remarks For Unusual Services
The standard ADA insurance claim form, as well as most other types of insurance forms, has an area for your remarks to further explain the treatment that was performed. To have your remarks printed on the insurance form, click on the Remarks For Unusual Services text box and enter those remarks there. The size of this box will vary depending on the insurance form selected. If line item memos were entered during posting, these memos can be pasted into the Remarks for Unusual Services box. This action is accomplish by clicking on the memo from page 1 of the Insurance Form Printing screen.

Print Office Fee Not Actual Fee Button
Click this button and the fees that print on the form will be your office fees, not the actual fees that were charged at the time of posting. This does not cause any change in the permanent record of the patient. The only effect will be on the claim form that prints.

Page 3 Screen Information - Primary Subscriber
After all the items of page 2 are entered properly, you may click on the Down Arrow page button at the bottom of the Insurance Form Printing screen to go to page 3. This page displays information as it will appear on the insurance form pertaining to the primary subscriber. Most of the items displayed on page 3 are for reference only and cannot be modified from this screen except for these following items:

• Prior Authorization Number - If you have previously sent in a claim for Prior Authorization, you might be required to enter the Prior Authorization Number on the claim for payment.  Enter that number here if applicable.
• Payment By Another Plan - If you are sending to the secondary insurance, you might be required to enter in what the primary insurance paid on the claim.  Use this field for that purpose.
• Claim Date - This is the date that will appear on the claim form.  This date will be entered automatically, but it can be overridden.
• First Visit Date (current series) - The program will automatically fill this in with the earliest date of a procedure that appears on the form, however, you  can override it.

Page 4 Screen Information - Secondary Subscriber
If the patient has dual coverage, a page 4 will become available for viewing. It will appear similar to page 3 except the information on it will pertain to the secondary subscriber.  There are no fields to enter on page 4.