New Dental/Vision Forms and MRA Applications

Please be aware of the new Dental/Vision Forms.  There is an updated mailing address on the form.  Please keep in mind effective February1, 2017 the only ones covered by our dental/vision insurance are dependents ages 19 and under.

Also note that these are to be used for member REIMBURSEMENT only.  Providers need to be submitting standardized claim forms in order to accept assignment benefits.

495 DENTAL-VISION CLAIM FORM 2016

We have added the quarterly MRA applications (Medical Reimbursement Forms) to this tab as well for your convenience.  Please print as many of these as you need.

MRA Form