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Dental Claim Form - Mamaroneck Teachers Association - mamaroneckta

Dental Claim Form - Mamaroneck Teachers Association - mamaroneckta 2026

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The document is a dental claim form for the Mamaroneck Teachers Association Welfare Fund, detailing the information required from both the employee and dentist to process dental claims. It includes sections for patient details, treatment specifics, accident information if applicable, and authorization for payment to the dentist.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the employee's name and mailing address in the designated fields. Ensure that all information is accurate to avoid processing delays.
Fill in the employee's birth date and relationship to the employee. This information is crucial for verifying eligibility.
Indicate if there are other dental coverages by answering the relevant question. If yes, provide details as requested.
For claims based on an accident, complete the section detailing when and where the accident occurred, along with a brief description of how it happened.
The dentist must complete their section, including their name, contact information, and license number. Ensure that all required signatures are obtained.
Review all entries for accuracy before submitting. Use our platform’s features to save your progress or make edits as needed.

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