How do I submit a Dental Claim?
Check with your dentist; they may be able to submit your claim electronically on your behalf. If not, you’ll need to send us the claim.
Information needed to complete the form
- member I.D. / Certificate Number
- Group policy number
- name of the insured person(s)
- relationship to the employee
- birth date(s)
- service provided
- original dentist statement or receipt or statement from your dentist or if you are coordinating claim’s payment with your spouse’s health plan, you should include the primary carrier’s payment statement
- information about other benefit or insurance plans that you may be eligible to claim from.
Steps to complete and submit the form electronically
- Download the D.A. Townley standard Dental Health Claim form (English/French).
- Save the downloaded form to your computer.
- Open and complete Part 2 and Part 3 the form in Adobe Reader. DO NOT complete the form in your browser. Get Adobe Reader from here (it’s free).
- Save changes to your computer, then close and re-open the form to ensure your information was saved.
- Scan or take pictures of your dentist statement or receipt and primary carrier’s payment statement.
Note: Our system only permits you to submit 9 receipts per claim!
- Email the saved Dental Claim form to firstname.lastname@example.org digitally using our secure Mail Express Tool. Here are the instructions on how to use it.
- Copy and save the Mail Express receipt number for your records.
- Do not print and mail the form to our offices.