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Dental
Claim Forms
To request approval
or reimbursement of dental expenses incurred or to seek preapproval
of future treatment, ask your dentist to complete Form 11. Attach
the invoice for services completed or a quote of work planned for
the future. Then, complete and attach Form 6, “KCDRB Form
6, LEOFF-1 Member’s Claim for Reimbursement of Medical Expenses.”
Submit all paperwork to your LEOFF-1 employer for direct reimbursement.
For detailed information, review these instructions.
You may only
claim charges not covered by dental insurance up to a maximum of
$3,000 per calendar year. Therefore, if you have dental insurance,
all invoices must first be submitted for reimbursement to your dental
insurance before making a claim to your LEOFF-1 employer. For more
information, refer to the dental information in Rule 9.9, page 41
of Rules, Policies and Procedures
(285 KB).
If necessary,
your LEOFF-1 employer may choose to forward your claim to the Disability
Board for final approval. If the reasonableness of charges or necessity
of treatment are questioned, the Board may require an independent
evaluation by a Board-selected dentist/specialist. If needed, a
request will be made to your dentist for all films, chart notes
or dental molds pertaining to the services and charges claimed.
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Form 11/
Form
11 (fill-in)
(dentist’s form). This form replaces Form 7 used for medical
claims. All dental claims need Form 11 completed by the dentist
and signed by you. Attach invoices for dental services, proof
of dental insurance payment (if applicable) and Form 6.
- Form
6/
Form
6 (fill-in)
(LEOFF-1 member's form). Every medical and dental claim must have
a Form #6 completed by you. Fill in all blanks, including the
list of service dates, name of medical provider and total dollar
amount of charges remaining after insurance.
- Form
5 / Form
5 (fill-in)
(employer’s form). This form needs to be completed by the
employer and attached to your claim before it is submitted to
the Board for review.
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