Claim Forms

Most providers will submit claims on your behalf, but if you need to submit your own claim, find out more information and download the forms below. Please consult with your provider to verify if you need to submit a claim.

Explanations of benefits (EOB) are available on AlwaysAssist once the claim has been processed. The EOB will provide, by procedure, the amount that was paid to the provider (if applicable) as well as any remaining balance that is the patient's responsiblity.

Dental Claim form

If you need to submit a claim, download the form and choose one of these options:

  • Return the completed form and a detailed receipt from your dentist via email here, or
  • Return the completed form via fax to 855-400-9307, or
  • Return the completed form via mail to:
    Claims Department
    P.O. Box 80139
    Baton Rouge, LA 70898-0193
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