FREE 8+ Dental Claim Forms & Samples in MS Word | PDF

Our oral health is closely related to our overall health since the mouth is the entry to the whole body and any infection occurring in the mouth can affect the entire body. That being said, it is important to always make sure that we are orally healthy. That is why dental insurance plans are important as well.

A Dental Claim Form is a formal document used for the reimbursement or payment of the dental expenses of insured members. Dental expenses could either be a checkup, or for preventive or restorative treatment. Browse through our samples below or check out our other Medical Claim Forms for more samples.

Member Dental Claim Form

Standard Dental Claim Form

Dental Insurance Claim Form

Dental Benefit Claim Form

Dental Medical Claim Form

Information to Be Included in a Dental Claim Form

• Policyholder’s Information: This will include the policyholder or insured member’s name, address, date of birth, and contact details. It will also include information about the dental insurance plan, such as the policy number. If applicable, this will also include the insured member’s employment details or educational details.
• Patient’s Information: In cases where the patient and the insured member are not the same person, this section is filled out. This also contains the personal information of the patient, along with the relationship of the patient to the insured member and some preliminary questions to help the dental insurance company reach a decision on whether or not to approve the dental claim. Examples are questions if the dental treatment was a result of an accident and if any dental treatments were received previously by the patient.
• Dental Clinic’s Information: This section is where the information of the dental clinic and the dental hygienist or dentist is indicated. This section is filled out by the dentist only. It includes information about the diagnosis and the dental procedures that were done. It could either be a preventive or restorative treatment. This will also be where the total expenses are stated. You may also see our Disability Claim Forms for filing a claim when you have a disability.

Dental Treatment Claim Form

Dental Claim Form in PDF

Dental Claim Form Example

Encon Dental Claim Form

Guidelines in Writing a Dental Claim Form

• When writing a Dental Claim Form, like any other Claim Form, always use a polite, friendly, and professional tone, even when you feel you have been wronged.
• It is important to fill out the forms completely and accurately, and provide necessary supporting documents to substantiate your claim, so that your claim will be approved. It will be even more tedious to apply for an appeal, and the process will be even longer compared to when you are just filing for a claim.
• In the event that your claim is denied, you may apply for a reconsideration or an appeal.

How Do Dental Claims Work?

The process for dental claim is just like any other medical or healthcare claims. The dental clinic or dentist will take the filled-out Dental Claim Form and submit it to your dental insurance company. Then the dental insurance company will duly process the claim and expend funds as payment for the covered dental expenses. Then they will forward any dental expenses that are not covered under your dental insurance plan and forward it to your dental clinic or dentist so that you can settle that balance directly with them. For additional resources, you may also look at our Health Care Claim Forms. There are various samples that you can download.