Box 99004 2026

1. Click ‘Get Form’ to open the Dental Claim Form in the editor.
2. Begin by filling out the Patient Section. Enter the patient's name, relationship to employee, sex, and birthdate in the designated fields.
3. Next, provide the employee's information including their name, mailing address, identification number, and employer's details.
4. Indicate if the patient is covered by another benefit plan and provide details of that plan if applicable.
5. In the Attending Dentist’s Statement section, check whether it is a pretreatment estimate or a statement of actual services.
6. Complete all relevant fields regarding dental services provided, including dates and descriptions of services performed.
7. Finally, ensure all signatures are obtained where required before submitting your completed form.

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