Dental Claim Forms

To request approval or reimbursement of dental expenses incurred or to seek preapproval of future treatment, ask your dentist to complete Form 11. Attach the invoice for services completed or a quote of work planned for the future. Then, complete and attach Form 6, “KCDRB Form 6, LEOFF-1 Member’s Claim for Reimbursement of Medical Expenses.” Submit all paperwork to your LEOFF-1 employer for direct reimbursement. For detailed information, review these instructions.

You may only claim charges not covered by dental insurance up to a maximum of $3,000 per calendar year. Therefore, if you have dental insurance, all invoices must first be submitted for reimbursement to your dental insurance before making a claim to your LEOFF-1 employer. For more information, refer to the dental information in Rule 9.9, page 41 of Rules, Policies and Procedures (285 KB).

If necessary, your LEOFF-1 employer may choose to forward your claim to the Disability Board for final approval. If the reasonableness of charges or necessity of treatment are questioned, the Board may require an independent evaluation by a Board-selected dentist/specialist. If needed, a request will be made to your dentist for all films, chart notes or dental molds pertaining to the services and charges claimed.

• Form 11 / Form 11 (fill-in) (dentist’s form). This form replaces Form 7 used for medical claims. All dental claims need Form 11 completed by the dentist and signed by you. Attach invoices for dental services, proof of dental insurance payment (if applicable) and Form 6.
• Form 6   / Form 6 (fill-in) (LEOFF-1 member's form). Every medical and dental claim must have a Form #6 completed by you. Fill in all blanks, including the list of service dates, name of medical provider and total dollar amount of charges remaining after insurance.
• Form 5   / Form 5 (fill-in) (employer’s form). This form needs to be completed by the employer and attached to your claim before it is submitted to the Board for review.