Physicians Mutual Insurance Company Dental Insurance Claim Form Dental Insurance Claim Form 2026

1. Click ‘Get Form’ to open the Physicians Mutual Insurance Company Dental Insurance Claim Form in the editor.
2. Begin by completing Part 1, which includes entering the patient's name, relationship to the insured, and date of birth. Ensure all fields are filled accurately.
3. Provide your address details in the designated fields, including city, state, and zip code.
4. Authorize the release of information by signing where indicated. This allows your provider to share necessary details for processing your claim.
5. Hand over the form to your dentist for them to complete Part 2. They will need to provide their information and details about the services rendered.
6. Once completed, review all entries for accuracy before submitting. Use our platform’s features to save or print a copy for your records.
7. Mail the completed form to the address provided: Physicians Mutual Insurance Company Dental Administrator: Ameritas Life Insurance Corp., P.O. Box 82520, Lincoln, NE 68501.

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