Get Dental Claim Form. - Operating Engineers Local 66

Completing the Dental Claim Form for Operating Engineers Local 66 can be straightforward when you have the right guidance. This guide will assist you in filling out the necessary sections with clarity and precision, ensuring a smooth processing of your claim.

Follow the steps to accurately complete your Dental Claim Form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In the Member/Policyholder section, enter your name and the name of your insurance company or dental benefit provider. Include the last four digits of your Social Security number.
3. Provide your signature in the Member/Policyholder section. This signifies your agreement and authorization for the claim.
4. In the Patient section, input the patient's name and last four digits of their Social Security number. Specify the patient's relationship to the member above, selecting from options such as Self, Spouse, or Dependent.
5. If you wish to utilize your Member Reimbursement Benefit, fill out the Member Reimbursement Benefit (MRB) section. Choose between the options to either reimburse the entire balance after the $50 Dental Benefit or specify an amount to reimburse from your Reserve after the $50 Dental Benefit.
6. Proceed to the Proof of Service section. Attach an itemized, detailed receipt for the dental services performed. Ensure that the receipt includes the following: Name of patient, Date of service, Procedure(s) performed, and Cost for service(s).
7. Review the completed form thoroughly to ensure all required fields are filled accurately, particularly the Proof of Service, as failure to provide complete information may delay the processing of your claim.
8. Once satisfied with the form, save your changes, and prepare to download, print, or share the completed Dental Claim Form as needed.

Complete your Dental Claim Form online today to ensure timely processing of your dental benefits.