Dental Waiting Period Waiver Request Form

Requester Full Name

First NameMiddle NameLast Name

Relationship to Insured Member

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Insured Member Full Name

First NameMiddle NameLast Name

Insured Member Date of Birth

Date

Preferred Contact Method

Dental insurer name

Plan or policy number

Group number

Employer or organization name

Coverage start date

Date

Waiting period end date or stated waiting period length

Member status

Reason Category

Specific Waiver Requested

Reason the Waiver Is Needed

Date Dental Treatment Is Needed or Was Recommended

Date

Type of Dental Treatment Needed

Urgent Clinical Need

Additional Explanation

Supporting Documents Included

Upload Supporting Documents

Attachment Notes

Declaration

Submission Acknowledgement