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  • Tricare Retiree Dental Program Claim Form

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Me (last, first, mi) and address Service type 1 completed services statement of pre-determination important: attach to this form the dentist s receipt for completed services or statement for pre-determination. Other coverage 3-9) 14 gender f yes 4 date of birth (mm/dd/yyyy) Patient information 5 gender m 6 employee ssn/id# f dependent 18 gender 19 if full-time student, list school and city m other 8a group number of other carrier 16 patient name (last, first, mi) 17 date of b.

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TRICARE covers adjunctive dental care. as part of the "medical" benefit. Dental coverage for diagnostic and preventive services, restorative services, orthodontics, oral surgery, endodontics and other non-medical services are provided under two different dental plans: TRICARE Active Duty Dental Program.

Dental plans are available through the Federal Employees Dental and Vision Insurance Program (FEDVIP), offered by the Office of Personnel Management. If you're eligible, you may be able to enroll in a FEDVIP dental plan.

Go to the Beneficiary Web Enrollment website. Click on the red "Log On" link at the top of the page. You must have a Common Access Card (CAC), DFAS (MyPay) Account, or a DoD Self-Service Logon (DS Logon) Premium (Level 2) account to log in. Select the "Dental" tab to enroll in a dental plan.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232