Patient Eligibility

TODAYS DATE
PROVIDERS OFFICE NAME
HNA DENTAL DISCOUNT ID#:
EMAIL (FOR ELIGIBILITY REPORT)
MEMBER'S NAME(First and Last):
MEMBER'S DATE OF BIRTH
PATIENTS NAME(First and Last):
PATIENTS DATE OF BIRTH
PATIENT APPOINTMENT DATE

NOTE: Information provided by HNA is valid for 24 hours after the date on the verification ticket

Provider to review correct fee schedule before any appointment set with patients. This is to ensure correct billing and understanding of all covered procedures.

HNA will not be held liable for services rendered.

The dental providers and other specialist providers that are part of the group of providers are independent contractors who exercise independent judgment and over whom HNA has no control or right of control and are not agents or employees of HNA. Members who seek care from a provider on our EPO list, either directly or by referral from another provider, are seeking care from that provider, not from HNA. Providers are required to exercise independent, professional judgment and it is the provider’s responsibility to discuss treatment options with Members, even those that might not be eligible for benefits under the Member’s Plan. HNA’s decisions about whether any dental service or supply is covered under the Member’s Plan are insurance benefit decisions only and are not the provision of dental care. HNA is not responsible for, does not provide, and does not hold itself out as a provider of dental care. Only the Providers who treat Members can provide dental care and only those Providers are responsible for any acts or omissions in providing dental care to Members. If a service or supply is not eligible for benefits, Members and Providers are free to proceed with that service or supply knowing that benefits are not available under the Member’s plan.

  Check here if you accept these terms.

Any Etickets sent after 4:30 PM PST, Monday-Friday, will be processed on the next business day.
We will generate patient’s eligibility and email the document back to your office.
If you have any questions, please contact us at 1-877-335-7526.

Disclaimer: This is not health insurance; the dental discount plan provides discounts from dental providers. The dental discount plan does not make payments directly to the providers of health care. The member will be required to pay for all dental treatment but will receive a discount from those providers that accept Health Networks of America’s Discount Dental Plan. Health Networks of America can be reached at 1-877-335-7526.