Dental Claim Form Page 2
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1
2Head 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
Please select one oF the FollowIng oPtIons:
o
I WANT MY ELIGIBLE EXPENSES PAID FROM MY EQUITABLE LIFE HEALTH OR DENTAL PLAN ONLY.
o
I WANT MY ELIGIBLE EXPENSES PAID FROM MY EQUITABLE LIFE HEALTH OR DENTAL PLAN FIRST AND MY UNPAID PORTIONS OF MY ELIGIBLE EXPENSES PAID FROM MY HCSA.
o
I WANT ALL MY ELIGIBLE EXPENSES PAID DIRECTLY FROM MY HCSA.
Please note:
IF you do not select any oF the above oPtIons, no PortIon oF thIs claIm wIll be PaId From your health care sPendIng account (hcsa)
PaRt 3 - PatIent InFoRmatIon
1. PatIent: RELATIONSHIP TO EMPLOYEE/PLAN MEMBER/SUBSCRIBER - __________________________ DATE OF BIRTH: (Day___________Month___________Year______________________)
o
o
IF CHILD, INDICATE:
STUDENT
HANDICAPPED
o
o
IS HE/SHE ATTENDING SCHOOL FULL TIME?
NO
YES IF YES, INDICATE SCHOOL: ________________________________________________________________________________
WHEN WILL HIS/HER SCHOOLING BE COMPLETED? (Day___________Month___________Year ______________________)
o
o
o
o
IS HE/SHE EMPLOYED FULL TIME?
NO
YES
IS HE/SHE EMPLOYED PART TIME?
NO
YES › HOW MANY PART TIME HOURS PER WEEK? __________________________
o
o
2. ARE DENTAL BENEFITS OR SERVICES PROVIDED UNDER ANY OTHER GROUP INSURANCE OR DENTAL PLAN OR CONTRACT?
NO
YES › IF YES, INDICATE THE FOLLOWING:
NAME OF OTHER INSURING AGENCY OR PLAN:_____________________________________________________________________________ POLICY NO: _______________________________
IF THIS PLAN IS ALSO WITH EQUITABLE LIFE
, PLEASE INDICATE MEMBER’S I.D.: _________________________________________________
®
o
o
DO YOU WANT US TO CO-ORDINATE BENEFITS (PROCESS BOTH CLAIMS)?
NO
YES › IF YES,
SPOUSE’S SIGNATURE: ____________________________________________________________________________
DATE: (Day___________Month___________Year ______________________)
o
o
3. IS ANY TREATMENT REQUIRED AS THE RESULT OF AN ACCIDENT?
NO
YES › IF YES, GIVE DATE AND DETAILS SEPARATELY.
o
o
A) ARE ANY DENTAL BENEFITS OR SERVICES PROVIDED UNDER ANY OTHER GROUP INSURANCE OR DENTAL PLAN?
NO
YES
(ie. School Insurance, Workers’ Compensation, etc.)
o
o
4. IS THIS CLAIM THE RESULT OF A MOTOR VEHICLE ACCIDENT?
NO
YES
o
o
5. IF DENTURE, CROWN OR BRIDGE, IS THIS INITIAL PLACEMENT?
NO
YES › IF NO, GIVE DATE OF PRIOR PLACEMENT AND REASON FOR REPLACEMENT.
o
o
6. IS ANY TREATMENT REQUIRED FOR ORTHODONTIC PURPOSES?
NO
YES
authorization & certification
I certify that the information given on this form is true, correct and complete to the best of my knowledge. The claim information willingly provided by me to Equitable Life held in their files, will
be used by Equitable Life for the purposes of claims processing and adjudication. I understand and authorize that for the above purposes the personal information on file is accessible to, and may
be exchanged with, authorized employees of, and relevant third parties retained by Equitable Life, its sales distribution network, participating reinsurer(s), other insurance companies, investigative
organizations, health care providers, including, but not limited to, pharmacies, physicians, dentists and any other person or party whom I authorize.
If applying for my spouse and/or dependents, I confirm that I am authorized to act on their behalf and therefore this consent and authorization also applies to the collection, use and communica-
tion of their personal information for the same purposes. I understand that claims made under the Group Insurance Policy are submitted through me as the plan member. I therefore authorize
Equitable Life to exchange information about these claims with me or any person acting on my behalf, including a spouse or dependent, as deemed necessary for the purpose of confirming eligibil-
ity and assessing and managing the claim
If you are submitting your claim form electronically (visit for more details)
o
Click to confirm and acknowledge your agreement with the above;
OR
If you are printing your claim form to email, fax or mail it to equitable life, provide your written signature to confirm and acknowledge your agreement with
the above:
Plan Member Signature
Date
Falsifying or tampering with claim documents / receipts could have legal consequences.
claim submission Instructions –
Please keep a copy of your claim form and receipts for your own records.
Electronic Submission - Visit or and use our EZ Claim
online feature to submit your Dental claim, along with your receipts and supporting documentation.
™
This is a secure and confidential portal for claim submission.
Alternatively, you can scan and email your claim forms, with receipts as attachments, to group-dental-claims@equitable.ca or fax your documents to 519.883.7406 or toll free to 1.888.505.4373.
Please NOTE: While using the internet and email is convenient, sending confidential and personal information through the Internet is not secure. E-mail is vulnerable to interception. Equitable cannot
ensure the privacy of information sent by email.
Mailing Instructions: Mail your completed and signed form to our Dental Claims department. Attach all receipts and supporting documentation. Please do not use staples.
Equitable Life of Canada; Attn: Group Dental Claims Department
One Westmount Road North
P.O. Box 1605 Waterloo, Waterloo Ontario N2J 0A8
520(2011/10/07)pg 2 of 2
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