Coordination of Benefits

If you or any other family member has other coverage that pays for your dental expenses in addition to GEHA, please complete the information below and select Submit Form to send this form by email to GEHA.

All fields are required unless marked as optional.

Employee or Annuitant Identification Data

To help us identify your account, please provide the following information.

Please enter a five-digit ZIP Code.
By providing your email address, you agree to receive email news and information from GEHA. You have the ability to opt out from within any email communication you receive from GEHA.

Other Group Coverage Information

Signature

By entering my name below, I certify that the information furnished by me is true and correct to the best of my knowledge and belief.