Dental Claim Form: Dental Claim Form 

Please use this form for dental claims, when the claim is not filed through your dentist.

Instructions for completing this form 

Please use the GO-510 form only for prescription drug claims when the claim is not filed through your pharmacist.

For Medical Claims, including Medicare: CMS-1500

We are unable to provide a CMS-1500 form electronically, since these forms use a red ink which enables them to be scannable using OCR equipment. This ink cannot be duplicated by regular PC color printers. Therefore, please call our Customer Service unit at 1-800-565-9140 to request a form.

You may also go to Centers for Medicare and Medicaid Services (CMS)  and choose CMS-1500. However, forms printed from their site will not be scannable and will result in delayed processing of your claim.