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32bj Dental Fund Form
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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