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Dental and Vision Forms


Claim Forms
  • Claim for Dental Expense Benefits
  • Vision Claim Form
  • Other Forms
  • Affidavit of Lost Policy Form
  • Bank Draft Authorization Form (In English) / (en Espaņol)
  • HIPAA Form (release PHI from provider) / Agent HIPAA Form (release PHI to agent) / Family HIPAA Form (release PHI to Family Member/Other 3rd Party)
  • Health Policy Cancellation Form



  • Additional Information

    Toll Free Number
    1-800-669-9030

    Email Us

    CS@manhattanlife.com



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