For Eligible Participants of the UFCW Local 1776 and Participating Employers Health and Welfare Fund FILING CLAIMS If you use a participating dentist The participating dentist will give you a claim form to sign when you receive treatment. Your dentist then bills the Fund directly. If the service you receive requires a co-pay or surcharge, you will be responsible for paying that fee directly to the dentist. If you use a non-participating dentist You must submit a claim form to the Fund office in order to receive the scheduled allowance for the procedure. Upon receipt of the completed claim form, the plan will pay the allowable amount either to you or to your dentist, depending on the assignment of benefits presented with the claim. To obtain a claim form, contact the Fund office. Please note, the rules concerning pre-authorization (described in the previous section) still apply when you use a non-participating dentist. Whether you use a participating dentist or a non-participating dentist, all claims must be filed no later than one year from the date of service in order to be considered for payment.