Dental Benefits Claim Form
1) All sections of this form must be completed by the member.
2) Attach a copy of the “Dentist’s Statement of Services” to this form and return both
within 90 days of date of service to the above address via U.S. Mail or District courier.
3) Do not give claims to your dentist to file for you.
4) The member is responsible for knowledge of all Trust Fund rules and regulations.
We certify that the foregoing statements and answers are true and complete to the best
of our knowledge and belief. A photocopy of this claim form shall be considered as
effective and valid as the original.
Patient Name Patient Date of Birth (Month Day Year) Patient Relationship to Member
If Yes, How Many?
Yes No
Yes No
FM
Yes No
Are X-Rays EnclosedIs Treatment the Result of an Accident?
Is Treatment the Result of Occupational Injury?
School
Date Signature of Member
Fund Use Only Fund Use Only
Name of Member Indicate your job title:Male/FemaleD.O.B
No
Other PlanYes
Contract
Individual
Administration
Retired
SRP
Teacher
COBRA
T/A
Patient Covered By Other Insurance? If Yes, Name The Other Plan
Address City, State, Zip Code
F
M
Name of Spouse
Male/FemaleD.O.B
/ /
/ /
Phone: (845) 562-79
88 • 52 Pierces Road Newburgh NY 12550
