The loomis company dental insurance 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part A – Employee Information. Fill in your name, relationship to the patient, and your home mailing address. Ensure all details are accurate for smooth processing.
3. Next, provide the patient's information including their birth date and whether they are a full-time student. If applicable, include the name of their school.
4. Continue by entering your Employee Member ID Number and details about your employer and dental plan. Indicate if the patient is covered by another dental plan.
5. Move to Part 2 – Treatment Information. Enter the dentist's name, address, and contact number. Specify if treatment is for orthodontics and provide relevant dates.
6. List all procedures performed using the charting system provided. Include fees for each service rendered.
7. Finally, ensure that both you and your dentist sign where indicated to authorize payment and confirm accuracy of information.

Start filling out your Loomis Company Dental Insurance form online for free today!