Dental Claim Form printable pdf download

Head Office

Group Dental Claims Department

One Westmount Road North

P.O. Box 1605 Stn. Waterloo, Waterloo Ontario N2J 0A8

TF 1.800.265.4556 T 519.886.5210 Fax 1.888.505.4373

Email group-dental-claims@equitable.ca

dental ClaIM FORM

UNIQUE NO.

SPEC.

PATIENT’S OFFICE ACCOUNT NO.

PaRt 1 - DentIst

I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS

CLAIM TO THE NAMED DENTIST AND AUTHORIZE

PAYMENT DIRECTLY TO HIM/HER.

LAST NAME

GIVEN NAMES

NAME

ADDRESS

APT.

ADDRESS

CITY

PROVINCE

POSTAL CODE

TELEPHONE NO.

SIGNATURE OF SUBSCRIBER (INSURED)

FOR DENTIST USE ONLY — FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES

I UNDERSTAND THAT THE FEES LISTED IN THIS CLAIM MAY NOT BE COVERED OR MAY EXCEED MY

OR SPECIAL CONSIDERATION

PLAN BENEFITS. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO MY DENTIST FOR THE

ENTIRE TREATMENT.

I ACKNOWLEDGE THAT THE TOTAL FEE OF $

IS ACCURATE AND HAS BEEN

CHARGED TO ME FOR SERVICES RENDERED.

I AUTHORIZE RELEASE OF THE INFORMATION CONTAINED IN THIS CLAIM FORM TO MY INSURING

COMPANY/PLAN ADMINISTRATOR. I ALSO AUTHORIZE THE COMMUNICATION OF INFORMATION

RELATED TO THE COVERAGE OF SERVICES DESCRIBED IN THIS FORM TO THE NAMED DENTIST.

SIGNATURE OF PATIENT (PARENT/GUARDIAN)

OFFICE VERIFICATION

DUPLICATE FORM

DATE OF SERVICE

INTL.

TOOTH

Day

Mo.

Yr.

PROCEDURE CODE

CODE

SURFACES

DENTIST’S FEE

LABORATORY CHARGE

TOTAL

THIS IS AN ACCURATE STATEMENT OF SERVICES PERFORMED

total Fee sUBmItteD $

AND THE TOTAL FEE DUE AND PAYABLE E. & OE.

Falsifying or tampering with claim documents / receipts could have legal consequences.

InstRUctIons FoR claIm sUBmIssIon

1. HAVE YOUR DENTIST COMPLETE PART 1, 2 AND 3.

2. AFTER PART 1 IS COMPLETE, SIGN PART 1 ACKNOWLEDGING DENTIST’S FEE.

3. ENSURE COMPLETION OF PART 2 AND 3 IN FULL. INCOMPLETE INFORMATION WILL DELAY THE PROCESSING OF YOUR CLAIM.

PaRt 2 - emPloYeR/Plan memBeR/sUBscRIBeR

1. GROUP POLICY/PLAN NO: ____________________________________________________ DIVISION NO: ____________________________________________________

EMPLOYER: ________________________________________________________________________________________________________________________________________________________

2. INSURED’S NAME (PLEASE PRINT): __________________________________________________________________________________________________________________________________

DATE OF BIRTH: (Day___________Month___________Year ______________________) INSURED’S CERTIFICATE/I.D. NO: __________________________________________________________

IF YoU have a health caRe sPenDIng accoUnt (hcsa) Please comPlete the FollowIng.

TO ENSURE YOU MAXIMIZE YOUR BENEFIT COVERAGE, REVIEW ANY COVERAGE YOU HAVE THROUGH ANY PROVINCIAL HEALTH INSURANCE OR PRIVATE PLAN AND CLAIM

ACCORDINGLY. A PRIVATE PLAN MAY INCLUDE BENEFIT COVERAGE YOU AND/OR YOUR DEPENDENTS HAVE THROUGH ANOTHER INSURANCE CARRIER. YOU MAY FIND IT USEFUL TO

REVIEW THE COORDINATION OF BENEFITS PROVISIONS IN YOUR PLAN MEMBER BOOKLET/BROCHURE.

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