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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.
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1
Name:
*
This field is required.
Name of patient in which services were preformed.
First Name
Last Name
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2
Email
*
This field is required.
Please provide an email so Bento can provide a status of your submission.
example@example.com
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3
Date of Service
*
This field is required.
Date
Year
Month
Day
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4
Bento Member ID
*
This field is required.
Please the Bento Member ID of the patient
Please include both letters and numbers
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5
Out-of-Pocket Amount ($)
*
This field is required.
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6
Upload Files
*
This field is required.
Please upload receipt or statement of balance bill. Name of member and date of transaction must be visible.
Drag and drop files here
Select files to upload
Upload a File
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Bento Dental Bill Upload
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