Dental Scan Time Claim
Submit your dental scan time claim with all required details below.
Claimant’s Full Name
*
First Name
Last Name
Dental Clinic or Practice Name
*
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient or Case Reference
*
Scan Date
*
-
Month
-
Day
Year
Date
Scan Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Scan End Time
*
Hour Minutes
AM
PM
AM/PM Option
Total Claimed Scan Time (minutes)
*
Reason for Claim and Supporting Notes
Submit Claim
Should be Empty: