Many dental offices are able to print a claim form for you off of their computer systems.  The form should include: patients name, service provided along with all the necessary codes and the dentists ID and NPI number and signature. 

This form should be submitted to the Fund Office by you or your dentist.  If your dentist provides a bill but does not provide a claim form, you can download the claim form provided below.

Please read the directions on the back of this form before submitting claim.   You may also contact our Dental Department for any questions you may have at 1-800-959-9497, Exts. 2236 or 2271

Downloads

	Name	Description	Download	Edit
	Dental Claim Form