Summary: Dental Reimbursement Request Form
Please submit to: Boynton Health Service Dental Clinic, 410 Church Street S.E., Minneapolis, MN 55455. Fax: (612) 625-0539.
Please keep a copy of this form for your records. For more information, contact us at firstname.lastname@example.org or (612) 624-0627, or visit the
Office of Student Health Benefits website at www.shb.umn.edu.
If you choose to have preventive dental work (such as a routine cleaning) performed outside of Boynton Health Service Dental Clinic, a one-time
credit (per academic year) of up to $150.00 can be refunded to you by check. Electing this reimbursement option means that you may not receive
free preventive treatment at your designated on-campus dental clinic during the plan year. To request this reimbursement, please submit the
following to Boynton Health Service within 45 days of the dental appointment. All three items must be submitted for your reimbursement request
to be processed.
1) this completed form,
2) a copy of your dental bill (must include your name and the treatment that was received), and
3) a copy of your payment receipt.
A. Primary Member Information
Name (Last, First, Middle Initial) (Please Print) Date of Birth (mm/dd/yyyy) U of M ID Number
Street Address, City, State, Zip Code Daytime Phone Email Address