Claim Your CHIP Extra Benefits

Complete the form below to receive your reward.

Extra Benefits Type

Extra Benefits Type

Member Information

First Name

Last Name

Date of Birth

Guardian / Head of Household Phone Number

Mailing address

City

State

Zip code

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

What Type of Gift Card Do You Want to Receive?

Email (Required for Digital Gift Card)

What Type of Gift Card Do You Want to Receive?

Email (Required for Digital Gift Card)

Complete the following quiz to claim your gift card.

1. Your child has a toothache. What should you do?

A. Call your child's main dentist and schedule a visit as soon as possible. B. Wait and see if the toothache goes away on it's own. C. Take your child to the emergency room to be seen.

2. You took your child to a hospital ER for a toothache. What should you do next?

A. Wait and see if the problem goes away. B. Call your child's Main Dentist and set up a follow-up visit. C. Plan on taking your child back to the emergency room for additional care.

3. Your child has a toothache, but you don't have a a Main Dentist. What should you do?

A. Go to DentaQuest.com and log into the secure member Website to find a dentist. B. Call DentaQuest member call center at 1-800-516-0165 and ask for help in finding a dentist. C. A or B.

4. When should you call your dentist for an immediate visit?

A. Your child has a broken tooth or a tooth has been knocked out. B. Your child has a pain from a cavity or lost filling. C. A or B.

5. When should you take your child to a hospital ER for oral care?

A. Your child has a serious mouth injury or infection making it difficult to breath or swallow. B. Your child may have a fractured or dislocated jaw. C. Both A and B.

I followed up with my child's main dentist and took the quiz within 30 days of a dental-related emergency room visit.

Yes No

Date Member visited the ER

What Type of Gift Card Do You Want to Receive?