Forms

It is easy to submit your request for reimbursement, or claim. Click the form you need below. The form will open in a new window. Simply fill in the form online and print it out and sign it. Then, mail or fax it to the address or fax number indicated. It couldn't be easier!

• Reimbursement Claim Form (This is a universal claim form for all reimbursement requests.  Please use this claim form if you are requesting reimbursement for Dental, Vision or Medical expenses per your employer's plan.)
• Orthodontia Treatment Plan Form

You will need the FREE Adobe Reader for these forms. Download your copy quickly and easily by clicking the Adobe logo below.