Claim Your Medicaid Extra Benefits

Complete the form below to receive your reward.

Extra Benefits Type

Member Information

First Name

Last Name

Date of Birth

Guardian / Head of Household Phone Number

Mailing address

City

Zip code

Medicaid Member ID Number

Your DentaQuest Member ID number is the 9- or 10-digit number on the front of your card

Date Member received care

Text input field

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