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Get 32bj Dental Fund

MATE (REQUIRED FOR INLAYS, CROWNS, BRIDGES, DENTURES, PERIODONTAL SURGERY, OR WHEN EXPENSES WILL EXCEED $300 IN A 90 DAY PERIOD) www.32bjdental.com PATIENT INFORMATION PAYMENT CLAIM (REQUIRED ON ALL CLAIMS ) Patient Name MEMBER INFORMATION PLEASE SUBMIT PRE-OPERATIVE X-RAYS FOR INLAYS, CROWNS, BRIDGES, DENTURES, PERIO SURGERY, ROOT THERAPY AND NON-ROUTINE EXTRACTIONS. X-RAYS OF FULL ARCH REQUIRED FOR ALL BRIDGE WORK. POST TREATMENT X-RAYS REQUIRED FOR ALL ROOT THERAPY CLAIMS. Birthdate Re.

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