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Samples & Forms

Samples

• Explanation of Benefits (EOB) sample (PDF)
• ODS ID Cards
  Medical: Front / Back (PDF)
  Medical/Dental: Front / Back (PDF)

Claim Forms

• Medical Claim

Credentialing Forms

• Practitioner Credentialing Application (PDF File)
• Credentialing Application Addendum (PDF File)

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Medical insurance products provided by ODS Health Plan, Inc. Dental insurance products provided by Delta Dental Insurance Company and administered by ODS.