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Dental expenses

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How to make a claim for you or your child

Use this form to request reimbursement for dental expenses covered by your plan.

To submit a claim:

  1. Print the form below.
  2. Ask your dentist to fill out Part 1.
  3. Fill out Parts 2 and 3.
  4. If you want your reimbursement paid directly to your dentist, sign the assignment box in the top right-hand corner of the first page.
  5. When the form is completed, please return it to the address on the form.

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