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