Dental Reimbursement Request Form
Employee's Name
*
Please Select
BABINAT, ROBERT SCOTT
BARNHART, EVAN
BECK, JENNIFER
BIBBY, COLETTE
BOYD, LAPREL
BURKE, CHRISTOPHER
CASTANEDA, ALBERT
CLAUSEN, STACIE
COFFELT, TYLER
CONLEY, LYNN
DEANE, KJERSTIN
ENOS, CHRISTOPHER
FOSDAHL, DEBORAH
FRANCIS, LISA
HALL, CHRISTOPHER
HEARNE, ALBERT
HEARNE, BRANDAN
HINTON, GREGORY
HUEMOELLER, DALE
JENSEN, PHILIP
KADY, MICHAEL
KIRKLAND, KATHLEEN
LAPASTORA, CHRISTIAN
MITCHELL, HEATHER
MOOG, ASHLEY
PLEITEZ, MICHELLE
REDEMER, JUSTIN
RICHARDSON, EVAN
SIERRA, MICHELE
SINISI, MEGAN
STEPHENS, JOHNNY RAY
VANEGAS, LAURA
WARD, AZEEM
Employee's Name
First Name
Last Name
Employee's Email Address:
*
example@example.com
Which calendar year is this entry for?
*
2025
2026
Patient's Name
*
First Name
Last Name
Does this patient have other dental coverage?
*
Yes
No
Spouse's birth date
*
-
Month
-
Day
Year
Date
Attach an Explanation of Benefits (EOB), for this claim, from the insurance company involved.
*
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of
Was any portion of this treatment cosmetic in nature or TMJ or orthodontics?
*
Yes
No
Amount of dental expense for which you are requesting reimbursement
*
Upload a copy of your dental payment receipt
*
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of
I certify that I, or my eligible dependent, have incurred the charges for which I am requesting reimbursement
*
Submit
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