11. Employee First Name
To Be Completed by Employee
Dental Expense Claim Form
1. Patient First Name
Middle Initial
2. Relationship to Employee
3. Sex
4. Married?
5. Patient Date of BirthMo. / Day / Year
6. For Office Use
7. If Full-Time Student  (Age 19 or Over)
9. If Disabled(Age 19 or Over)
10. Name of Group Dental Program
12. Employee Date of Birth
13. Office Phone (Area Code)
14. Employee Residence Mailing Address
15. City, State, Zip
16. Are other Family Members Employed?
Name of other Employed
His/her ID Number
17. Date of Birth
18. Name and Address of Employer for Item 16
19. Is Patient Covered by Another Dental Plan?
If Yes, complete the following:
Dental Plan Name
Group No.
Name and Address of Carrier
20. I Authorize Release of any Information Relating to this Claim.
21. I Certify that the Above Information is Correct.
22. I Authorize Payment Directly to the Below-Named Dentist.
(Signature of Patient or Signature of Authorized Representative if Minor)
Employee Signature
Dentist's Office Name
Dentist's Provider # (ask your dentist)
Submit this form to HR. Click Submit when the above is complete.
 In addition - Print this Form, fill out the bottom portion and Fax to 999999999.  Your signature is required!
The Flow of Information does not need to be 'one way'.  The example below shows how personalized information can be received from an employee via the web or intranet for Self Administered Dental Claims submission.
Each 'data field' (Patient First Name, etc.) could be a Column in a Table.  When the Form is submitted, the following occurs:
As the employee was filling out the Form, information would be getting temporarily stored in their browser (Javascript). Click on Item 2 (Relationship to Employee). In this case - and also the other Radio buttons, a Value would be assigned (review the Properties).  So Self may be a 1, Spouse a 2 ... and so on.  For Item 10 (Group Dental Program), an integer would also be assigned -- that would match your current HRIS.  We drew the Form, but an easier method:If available as a paper form:Scan the form, Place the image as a background - then add the form elements.  You'd be done in ~ 1 hour (including the Table), probably less.
for Submit to actually take place:1) Need a Table with Columns2) Each item below could be assigned a 'Control datafield' - which would represent a corresponding Column in the Table. 3) The Submit button would need an onClick event.  Select the Submit button, then on the Properties palette - select Events.  You'll see what we mean.4) An Action (Php) would cause the submitted data to be inserted into the Table.  This form now submits.  We'll put up an additional page soon that will display the results.
This form was reconstructed from a paper based form actually being used by a Carrier.  It is horrendous on so many levels - but it does help us to better understand why the US Healthcare industry is grappling with data and the flow of information.  A quick glance shows us that Item 15 should be 'decomposed' into 3 items.  Otherwise, it will be a nuisance to clean up in the Table & queries.  Item 16 - huh?The unnumbered items sandwiched in between 16 and 17?  What if 3 family members are employed?  His/her ID number? Would that be employee number, plan ID number?  Anyway, enough ranting -- click stuff, then review what is what on the Properties palette.
The submit button has an onclick event.Select the submit button, then click on Events -> Assign (Properties).  A dialog will pop up. Look at the simple javascript by selecting onClick -> Edit Action.
What's up with all the blue?Just above it is a white filler that is set to Fill page - Vertical, which is why you don't see it on the web. Click the white filler (the note is sitting on it), then look at the Properties palette.