Dental Reimbursement Request Form
Employee's Name
*
First Name
Last Name
Employee's Email Address:
*
example@example.com
Which calendar year is this entry for?
2021
2022
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
*
Clear
Submit
Should be Empty: