Claim Your Medicaid Extra Benefits

Complete the form below to receive your reward.

Please briefly explain your license request below

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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