Dental expenses
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.
Use this form to claim expenses relating to dental treatment. Your dentist will need to complete some sections.
Not forms you're looking for? Go back to the find a form page.