Common use of Claim Form Clause in Contracts

Claim Form. i. Within 15 days after receiving a notice of a claim, you or your Dental Provider will be provided with a Claim Form to make claim for Benefits. To make a claim, the form should be completed and signed by the Provider who performed the services, and by the patient (or the parent or guardian if the patient is a minor), and submitted to the address above. ii. If a Claim Form is not sent to you or your Provider within 15 days after you or your Provider gave notice regarding a claim, the requirements for proof of loss outlined in the section “Written Notice of Claim/Proof of Loss” above will be deemed to have been complied with as long as you give written proof that explains the type and the extent of the loss that you are making a claim for, within the time established for filing proofs of loss. You may also download a Claim Form from the dental plan website at xxx.xxxxxxxxxxxxxx.xxx.

Claim Form. i. Within 15 days after receiving a notice of a claim, you or your Dental Provider will be provided with a Claim Form to make claim for Benefits. To make a claim, the form should be completed and signed by the Provider who performed the services, and by the patient (or the parent or guardian if the patient is a minor), and submitted to the address above. ii. If a Claim Form is not sent to you or your Provider within 15 days after you or your Provider gave notice regarding a claim, the requirements for proof of loss outlined in the section Section “Written Notice of Claim/Proof of Loss” above will be deemed to have been complied with as long as you give written proof that explains the type and the extent of the loss that you are making a claim for, within the time established for filing proofs of loss. You may also download a Claim Form from the dental plan website at xxx.xxxxxxxxxxxxxx.xxx.