NNEBT

Resources and Forms

Dental Fee Schedule - 2010	Prescription -Credit Card Authorization
Dental Fee Schedule - 2009	Prescription - Mail Order Form
Dental Fee Schedule - 2008	Prescription - Patient Profile
Dental Fee Schedule - 2007	Prescription - Prior Authorization Form
Breakdown of Frequency Benefits	Prescription - Authorization Release Form
Disability Claim Form (Short Term)	TBH Release of Information
Health Club Reimbursement Claim Form	TBH Treatment Plan
Massage Therapy Claim Form
These forms are posted here for your convenience. Not all benefits represented here pertain to every plan. Please be certain to check your employer's plan benefits to ensure that you are eligible for the benefit.