Dental benefits request form 2026

1. Click ‘Get Form’ to open the dental benefits request form in the editor.
2. Begin by filling out the employee's information in blocks 1-8, including your name, Aetna ID number, and contact details. Ensure you use black ink for clarity.
3. Complete blocks 9-22 with patient details, including their relationship to you and any relevant employment information. If applicable, indicate if the claim is related to an accident.
4. In block 28, authorize the release of information by signing your name. This step is crucial for processing your claim efficiently.
5. If you wish for benefits to be paid directly to your dentist, sign block 29. This ensures a smoother transaction for both parties.
6. For dentists completing the form, check the appropriate box in block 30 and fill out blocks 31-48 with service details and fees.

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