Employee Name: _________________________________________________________ Employee SSN#: __________________________________________________________ Street Address/PO Box: ____________________________________________________ City: ______________________________ State: ________________Zip:____________ Phone Number: ___________________________________________________________ Patient's Name: _____________________________Relationship:__________________ Date of Claim(s): _____________________Amount of Claim(s):__________________ PLEASE NOTE: All claims for the plan year must be filed within 90 days after the charges were incurred. DO YOU HAVE OTHER DENTAL INS? IF YES, LIST NAME OF INS CO & PHONE # _______________________________________________________________________________ ARE BENEFITS TO BE PAID TO THE DENTIST? YES ______ NO ______ IF YES, I HEREBY AUTHORIZE PAYMENTS DIRECTLY TO THE DENTIST. Signature _______________________________________ Date _____________ Please attach receipts and the EOB from your other insurance co (if you have other insurance) And mail or fax to: PBA 14141 46th Street N #1205 Clearwater, FL 33762 Phone 727-532-1722   Fax 727-530-4816