Dental expenses claims forms

Have coverage through your employer or plan sponsor? You’re in the right place.

If you have coverage through an advisor, use our personal insurance forms instead.

Start a paper claim

Use these forms to make a dental expenses claim. You'll find instructions for submitting each form on the form itself.

Download this form and print it, or fill it out in Adobe Reader XI or higher - Opens in a new window (not your browser) and save.

Standard dental claim form - M445D (WPG) BIL PDF 196 kb

Use this form to make a claim for dental expenses. You'll need the dentist to fill in some sections.

Dentalcare Expenses Statement With Healthcare Spending Account PDF 215 kb

If your plan includes a healthcare spending account, use this form to make a claim for dental expenses. You'll need the dentist to fill in some sections.
Health SolutionsPlus dental claim form - M445D (HSPT-W) PDF 211 kb

If you have a Health SolutionsPlus Visa card, use this form to make a claim for dental expenses. You'll need the dentist to fill in some sections.
Medical Reimbursement Plan (MRP/Cost-Plus) expense statement (direct submit) M6734 PDF 121 kb

Use this form to claim health care, vision or dental expenses if you're covered under a medical reimbursement plan.
Medical Reimbursement Plan (MRP/Cost-Plus) expense statement (Group Authorized) M6735(GA) PDF 123 kb

Use this form to authorize a claim for health care, vision or dental expenses if you're a group contract holder.