DENTAL CLAIM bFORM ELECTRICALb WELFARE TRUST FUND - ewtf 2026

1. Click ‘Get Form’ to open the DENTAL CLAIM FORM in the editor.
2. Begin by checking the appropriate box for either the Dentist’s Pre-Treatment Estimate or Dentist’s Statement of Actual Services.
3. Fill in the patient’s name, relationship to employee, and birthdate. Ensure all fields are completed accurately.
4. Provide details about the employee, including their name, social security number, and employer's information.
5. Indicate if there is any other dental or medical coverage and provide relevant insurance details if applicable.
6. Complete the dentist's information section, including their name, license number, and contact details.
7. List all services performed using the charting system provided. Include dates and descriptions for each service.
8. Review your entries for accuracy before signing at the bottom of the form to authorize payment directly to the dentist.

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