Date
Insurance company name
Insurance company address
re: John Doe, claim #1234546779
Supplemental information for the accompanying claim
Existing conditions:
- 2 Missing; extracted over 20 years ago.
- 3 Missing; extracted over 20 years ago.
- 4 Recurrent M caries under failing MODL composite; less than 50% of supragingival tooth structure present.
- 5 New D caries
- 13 Deep D caries undermining B & L cusps; temporary DO filling; MO amalgam; less than 50% of supragingival tooth structure present.
- 15 Failing MODB composite; replaces DB cusp; has multiple fractures; less than 50% of supragingival tooth structure present.
- 18 Had Root Canal Treatment completed Oct 7, 2002; never been crowned; massive caries has left less than 50% of supragingival tooth structure present.
- 19 MO, B amalgams; recurrent D caries under deep DO composite undermines DB cusp; less than 50% of supragingival tooth structure present.
- 20 Recurrent D caries.
- 30 MO amalgam; recurrent D caries under DOBL composite replacing DB, DL cusps; less than 50% of supragingival tooth structure present.
- 31 New M caries.
- All Moderate to Severe occlusal & incisal attrition from bruxism; causing dentin exposure, mobility, rapid deterioration of restorations.
