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Coordination of Benefits

If you have other insurance that includes dental benefits, please complete the form below.

*Nevada Medicaid Member First Name
*Nevada Medicaid Member Last Name
*Nevada Medicaid ID Number
Name of other insurance company
Other insurance address/phone
Name of family member insured thru them
Relationship of family member to Nevada Medicaid member
Effective date of other coverage
Group, Policy, Member Numbers of other coverage
Type of other coverage

Please only click Submit once