Submit a Rebate Form

If you are already enrolled in the study, you can submit a Rebate Form by choosing one of the following methods.

Once the Rebate Form is received, the study staff will review the form, verify the details with your dental provider and process it for you.

1) Submit an Online Rebate Form

You can submit an online Rebate Form by following the steps below.

1) Click on the link to open the online Rebate Form.

2) Follow the instructions on the survey and fill out the Rebate Form.

Once you click “Submit”, the study staff will receive the form. The information you submit is confidential and will only be reviewed by the study staff.

2) Print and Mail the Rebate Form

You can mail a completed Rebate Form to the study team by following the steps below.

1) Click here to open the Rebate Form.
2) Download the Rebate Form and print it out.
3) Follow the instructions on the form to fill it out.
4) When the Rebate Form is ready to be submitted, mail it to the following address:

ATTN: UCM Dental Care Research Study
5841 South Maryland Ave MC 1005, Room M209
Chicago, IL 60637

3) Print and Bring the Rebate Form to your Next Appointment

You can submit a completed Rebate Form to the study team during your next appointment by following the steps below.

1) Click here to open the Rebate Form.
2) Download the Rebate Form and print it out.
3) Follow the instructions on the form to fill it out.
4) When the Rebate Form is ready to be submitted, bring it to your next appointment and give it to a member of the study team.

Do you have questions?

Although submitting the online Rebate Form might be faster and is the preferred option, all forms will be reviewed in the order in which they are received. Please reach out to the study team if you have any questions or concerns.

Phone number: (773) 702-8617

Email: oralhealth@medicine.bsd.uchicago.edu