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32bj Dental Fund  Form

32bj Dental Fund Form

Use a 32bj dental 0 template to make your document workflow more streamlined.

BRIDGES, DENTURES, PERIO SURGERY, ROOT THERAPY AND NON-ROUTINE EXTRACTIONS. X-RAYS OF FULL ARCH REQUIRED FOR ALL BRIDGE WORK. POST TREATMENT X-RAYS REQUIRED FOR ALL ROOT THERAPY CLAIMS. Birthdate Relationship to Member Spouse Child Full Time College Student Yes No If over 19, student verification is required each semester and must be filed with the Fund. (REQUIRED ON ALL CLAIMS) Member Name Birthdate Street Address Sex City Social Security # State Zip Telephone # ( Policy/Plan...
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