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Get AFLAC HF004 2019-2024

your dentist’s office to complete the entire form. Blank fields will cause the form to be returned and the claims processing to be delayed. We must have the following information: • • • • • The policyholder’s dental policy number (please leave the Group field blank). The policyholder’s complete name as it is printed on the dental plan ID card. The patient’s full name, sex, date of birth and relationship to the insured. The treatment date, tooth or surface repaired, oral cavi.

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