Samples & Forms
Samples
Explanation of Benefits (EOB) (PDF File)
Payment Disbursement Register (PDR)
- Basic Claim (PDF File)
- Alternate Benefit (PDF File)
- Overpayment (PDF File)
- Wrong Patient Adjustment (PDF File)
Forms
Warning: Acrobat Reader does not allow you to save your completed forms; they must be printed.- Credentialing (PDF File)
- Recredentialing (PDF File)
- ODS Dental Claim (PDF File)
- Survey of Charges - General Dentist (PDF File)
- Survey of Charges - Endodontist (PDF File)
- Survey of Charges - Oral Maxillofacial Surgeon (PDF File)
- Survey of Charges - Orthodontist (PDF File)
- Survey of Charges - Pediatric Dentist (PDF File)
- Survey of Charges - Periodontist (PDF File)
Oral Health, Total Health Enrollment
OHP Forms
- Interpreter Request (PDF File)
- Member Authorization (PDF File)
- Patient Responsibility Waiver (PDF File)
- Specialist Referral Request (PDF File)
Brochures & Guidelines
OHP Brochures & Guidelines
These resources are available for your reference and can be printed and given to OHP patients.
- Pregnancy and Your Teeth* (PDF
File)
This flyer emphasizes taking care of your teeth while you are pregnant. - Take Time for Teeth* (PDF
File)
This brochure informs parents on how to care for their young child’s teeth to prevent early childhood caries. - Immediate Denture Brochure (PDF
File)
This brochure will inform your patients about how to take care of immediate dentures and what to do after surgery.
*Spanish and English versions included in document