Company Address City State Zip Claims Examiner Phone Fax	Claimant Insured Date of Loss Claim No. Provider of Services (may include complete address) Your Email Address Note: Please enter a valid email address because a copy of the completed form will be sent to you by email.
Has This Claim Been Previously Reviewed? No Yes If Yes, NADENT #: Date: Claim Type: Comp Auto Liab Other Rush - Additional Fees Apply: No  Yes File Attachment 1:  File Attachment 2:  File Attachment 3:  File Attachment 4:  File Attachment 5:  File Attachment 6:  File Attachment 7:  File Attachment 8:  File Attachment 9:  File Attachment 10: Note: You are limited to 10 attachments. If you need to attach more documents, please fill out another online claim form indicating this or send the additional attachments to nadentsouth@nadent.com with a note.

PLEASE CHECK TYPE OF SERVICE REQUESTED:
REVIEW OF RECORDS FOR CAUSALITY INCLUDING REVIEW OF FEES.	FEE AUDIT ONLY.	PHYSICAL EXAMINATION INCLUDING REVIEW OF RECORDS & FEES.
The following information is needed: X-RAYS TREATING DENTIST REPORT EMERGENCY ROOM RECORDS FIRST REPORT OF INJURY TMD REVIEW: IN ADDITION TO ABOVE ANY DIAGNOSTIC REPORTS AND NARRATIVES FROM OTHER PROVIDERS (NEUROLOGISTS, CHIROPRACTORS, ORTHOPEDISTS, ETC.) SIGNED AUTHORIZATION TO RELEASE RECORDS	The following information is needed: TREATMENT PLAN & FEES	The following information is needed: TREATING DENTIST REPORTS X-RAYS (IF AVAILABLE) EMERGENCY ROOM RECORDS FIRST REPORT OF INJURY ATTORNEY'S NAME & ADDRESS CLAIMANT'S NAME & ADDRESS OTHER HEALTH PROVIDERS DIAGNOSTIC REPORTS SIGNED AUTHORIZATION TO RELEASE RECORDS

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Claimant's Information Name Address Address City, State, Zip

Attorney's Information Name Address Address City, State, Zip