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Cigna Dental Oral Health Integration Program Reimbursement Form Proof of Payment Dental Explanation of Benefits (EOB) OR Itemized Receipt from Dentist OR, Completed Claim Form (primary and secondary if applicable) Cigna Dental P.O. Box 188044 Chattanooga, TN 37422-8044 A. INSURED/SUBSCRIBER INFORMATION INSURED/SUBSCRIBER NAME: (Last, First, Middle Initial) (State) (City) ADDRESS: (Street) TELEPHONE NUMBER: EMPLOYER NAME: E-MAIL ADDRESS: OTHER DENTAL OR MEDICAL COVERAGE? Yes SSN OR CIGN.

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