Get Bupa Reimbursement Form

Filling out the Bupa Reimbursement Form online is crucial for ensuring that you receive the benefits owed to you for dental treatment. This guide provides clear and detailed instructions on how to complete each section of the form to help streamline the reimbursement process.

Follow the steps to complete the Bupa reimbursement form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your browser.
2. Review the membership details section. Ensure that your Bupa Dental membership number, company name, and scale of cover are correctly filled out. If any information is incorrect, amend it accordingly.
3. In the employee/member details section, provide your title, surname, forename(s), preferred telephone number, gender, date of birth, and home address, including the postcode.
4. If the patient receiving treatment is different from the member, complete the patient details section with the patient's title, surname, forename(s), gender, and date of birth.
5. In the dental treatment details section, your dentist should fill in the procedure code, type of treatments provided, the tooth or teeth treated, treatment dates, total patient charge, and relevant NHS banding if applicable.
6. The dentist must also complete their declaration, indicating whether the treatment was routine, emergency, or due to a dental injury, and provide their stamp, signature, name, position, and date.
7. If applicable, in the solicitor details section, provide the solicitor's name, reference number, address, and the date of the accident.
8. In the other insurer details section, provide the name of any other insurer covering dental treatment, along with the policy number and address.
9. Complete the claim details section, noting the total treatment costs and the number of receipts you are enclosing with the claim.
10. Ensure payment details are filled out correctly, including the account holder name, bank/building society name, sort code, and account number for direct payment.
11. Finally, fill out the patient’s declaration, ensuring that both the patient (or parent/guardian if under 16) and dentist have signed where necessary before submitting the form along with original dated receipts.

Complete your Bupa reimbursement form online today to secure your dental benefits.