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INSTRUCTIONS: SOUTHLAND DENTAL CLAIM FORM 

Alabama public employees are enrolled with Southland Benefit Solutions for their health insurance. Those needing to make a claim for reimbursement for dental treatment should file the form discussed in this article, which is found on the website of the Retirement Systems of Alabama.

Southland Dental Claim Form Step 1: In box 1, indicate with check marks what type of transaction this form documents. In box 2, enter your predetermination or preauthorization number. In box 3, enter the name of your insurance company or dental benefit plan and its address.

Southland Dental Claim Form Step 2: Box 4 asks you to indicate with a check mark if you have other dental or medical coverage. If you check "No," skip to box 12. If you check "Yes," you must complete boxes 5 through 11.

Southland Dental Claim Form Step 3: In box 5, give the name of the policyholder of the other insurance or dental benefits plan. In box 6 give their age, indicate their gender in box 7, give their subscription identification number in box 8, and their plan or group number in box 9. Indicate the patient's relationship to the policyholder with a check mark in box 10. Give the name of the plan and its address in box 11.

Southland Dental Claim Form Step 4: In box 12, enter the name of the policyholder or subscriber to the dental or medical insurance plan for which you are submitting a claim. In box 13 give their date of birth and indicate their gender with a check mark in box 14. Enter their subscription identification number in box 15, their plan or group number in box 16, and their employer's name in box 17.

Southland Dental Claim Form Step 5: In box 18, indicate with a check mark if the patient is the policy holder or their spouse or child. If you are a student, indicate whether you are part or full time in box 19. In box 20, give the patient's name and address. In box 21, give their date of birth. In box 22, indicate their gender with a check mark. In box 23, give the patient's identification or account number. 

Southland Dental Claim Form Step 6: Sections 24 through 33 document all services provided. Boxes 34 and 35 concern missing teeth. The patient and dentist should complete all sections below.