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Submit an Reimbursement
Submit an Reimbursement
Please complete the form with all service information in order for Bento to process your claim. Attached your invoice, receipt or ADA claim form your office provided you. 
Bento Dental Bill Upload
  • 1
    Name of patient in which services were preformed.
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  • 2
    Please provide an email so Bento can provide a status of your submission.
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  • 3
    Pick a Date
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  • 4
    Please the Bento Member ID of the patient
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  • 5
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  • 6
    Please upload receipt or statement of balance bill. Name of member and date of transaction must be visible.
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Bento Dental Bill Upload
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