Location

6110 McFarland Station Drive Ste# 503,Alpharetta, GA 30004.

Email

hr@bedatatech.com

Call Us

847-960-4204

Forms

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Applications & Enrollments

Cleaning Form for Pregnant and Diabetic Members
IN Dental Self Enrollment
Provider Nomination Form
Provider Nomination Form - Dental

Authorization & Verification

Dental Impaired Dependent (Michelle's Law) Application
Member Authorization Form - Dental
Member Authorization Form - Medical

Claims

Dental Claim Form
International Claim Form(BlueCross BlueSheild Global Core)
Medical Claim Form
Prescription Drug Clain Form
Prescription Drug Claim Form - Express Scripts
Qualified Healthcare Expense Claim Form
Vision Out-of-Network Claim Form

Life & Disability Insurance

ABCBS Supplemental Products Claimant Statement

Notices

Emergency Dental Treatment for the International Traveler
International Emergency Dental Program Frequently Asked Questions

Pharmacy

Home Delivery Order Form
Prescription Drug Claim Form

Pharmacy (Using Express Scripts)

Home Delivery Order Form – Express Scripts
Prescription Drug Claim Form – Express Scripts


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