Health Benefits LocationsTrustmarkFile a ClaimTrustmarkDental Claim Form - HealthplexClaim form - BCBSKS 2026

1. Click ‘Get Form’ to open the Dental Claim Form in the editor.
2. Begin by filling out the Employee Information section. Enter the Patient Name, Relationship, and Employee Name (First, Middle, Last). Ensure you include the Employee Member Number and Address details.
3. Complete the Employer Name, City, State, and Zip Code fields. Indicate if other family members are employed and provide their details if applicable.
4. In the Patient's section, fill in their Sex, Birthdate, and if they are a Full-Time Student, list their School and City. Include any additional insurance information if applicable.
5. Authorize the release of information by signing in the designated area. If applicable, authorize payment directly to the dentist by signing again.
6. The Dentist must complete their section with their name, address, and relevant details about treatment. Ensure all services are listed accurately along with dates.
7. Review all entries for accuracy before submitting your claim through our platform.

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