Download a Claim Form HIPAA Authorization Form Use this form to authorize someone else to access your information in order to help you manage your dental and/or vision benefits.

We have Claim forms for: Each product – Medical, Life, and Long-Term Disability (LTD) each have their own Claim form below. Language options – Forms are available in English and French.

Complete your section of the claim form (items 1 through 21) in full to assure positive identification and prompt payment. Please print or type. Note: Item 8 (ID Number) must be completed for the claim to be processed.

If you download a form we recommend that you bring a claim form with you when you visit your dentist for an appointment. Disability and Absence Management MetLife makes it easy and efficient to file your disability claim or report your leave of absence.

• If you are requesting that the form be translated into Spanish or Chinese, please visit our website, www.metlife.com, and download the applicable claim form from our Dental Insurance Center. • Or you may mail the entire four (4) pages of this form to the address shown on page 4.

You can arrange for MetLife to make payment directly to the dentist by completing item 22. If you wish benefits to be paid directly to yourself, do not complete item 22.

Complete your section of the claim form (items 1 through 21) in full to assure positive identification and prompt payment. Please print or type. Note: Item 8 (Employee Social Security / ID Number) must be completed for the claim to be processed.

You can complete the claim form you received in your claim kit and send to MetLife via mail, fax, email or complete the claim form online. Please see Frequently Asked Questions below for more details.

The completed claim form should be sent to MetLife prior to die commencement of die course of treatment. MetLife will review the claim (and any supplementary information required) and notify your patient of the benefits payable.

The purpose of the MetLife Dental Expense Claim form is to facilitate claims for dental services rendered to policyholders. This document allows subscribers to accurately report expenses incurred and request reimbursement accordingly.