If at any time you wish to cancel and return to the Dentist Connection menu, click here.
Please fill out the following form to contact a Benefit Services Representative. A red outline will appear around the field when required information is missing or incomplete. Mouse over the field for instructions.
The following office-specific information is required:
Office Contact Name Provider ID Practice Email Address
When applicable to your query, please provide the following information about your patient. This information is required for requesting a faxback of patient benefits. If your query does not concern a patient, the following fields are not required.
Subscriber ID Patient First Name Patient's Date of Birth (mm/dd/yyyy)
Enter your comment or question below:
If we require additional information, we may need to contact you by phone or fax. Please provide your office's phone and fax number, including area code:
Office Phone Number Office Fax Number
Before clicking Submit, please verify your contact name, Provider Id, practice email address and office phone and fax numbers. If the information is invalid, we will not be able to follow up on your request.