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.
Submit your claim online
Your online account makes it easy to submit your claims online or print forms that are pre-filled with your personal information.
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.
Standard claim form
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.
Use this form to make a claim for dental expenses. You'll need the dentist to fill in some sections.
Plan-specific claim forms
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.
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.
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.