Submit a Claim by mail.
1.Click here to download a claim form.
The claim form is in Adobe® PDF format. If you do not have Adobe® Acrobat Reader®, which will enable you to view and print the claim form, click here to download a free copy.
2. Complete the form and be sure to sign it.
3. Mail your completed, signed form to:
P.O. Box 7402
London, KY 40742
Dentists can submit electronic claims using Emdeon Payor IS:CX049