Town of
Dental Claim Reimbursement Form
Always use this form when you have a dental expense. If the
provider does not accept assignment of benefits, or does not file the claim
directly with The P&A Group, complete and sign this form and send to the
P&A group. If your dentist will file
your claim directly with The P&A Group, take this completed form to your
dentist's office and have them send it to P&A.
This section must be
completed by the employee: The employee ID is the last 4 digits of the SS# plus
employee month and day of birth (####MMDD)
Name of Employee: Employee
ID:
Email Address:
Please check if you do not have
an email address o
Name of Patient:
Patient's relationship to
employee: o Self o Spouse o Son o Daughter
Is this claim for a
spouse/dependent with primary coverage in another plan? o Yes o No
If Yes, please
attach a copy of the Explanation of Benefits.
Name of other company:
Amount of Expense Incurred:$
Service Date: (one
claim form per date of service)
Please check the appropriate box(es):
o Please send the eligible amount of reimbursement from the plan directly
to the dental provider and use my flex account to pay any remaining balance
(out-of-pocket expense) to the dentist.
o Please send the eligible amount of reimbursement from the plan directly
to the dental provider and I will take care of paying any remaining
balance (out-of-pocket expense).
o Please send the eligible amount of reimbursement from the plan directly
to me and use my flex account to pay any remaining balance (out-of-pocket
expense) to me.
o Please send the eligible amount of reimbursement from the plan directly
to me and I will take care of paying any remaining balance
(out-of-pocket expense).
I authorize The P&A Group
to process this claim and to request information from the provider if/as
necessary to process the claim. I certify that the information on this form is
accurate and true to the best of my knowledge.
Signature of Employee Date
Please include the ORIGINAL insurance
claim form from your provider that includes diagnosis and/or procedure code(s)
and mail OR fax to:
P&A Group
17 Court
Customer Service - Toll Free # 800-688-2611
Toll Free Fax # 877-851-8906
**Attention Dental offices
Only**- Please make sure your attached invoice / claim form
includes your tax ID number, address, and phone number to ensure prompt
reimbursement. Online claim submission :
http://Dental.padmin.com.
Insurance fraud is a felony.
Any person who knowingly and with intent to defraud, files a statement of claim
containing any materially false, incomplete or misleading information, is
subject to disciplinary action by the Town of