Group Benefits Dental Claim Form
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1
2Group benefits
Dental Claim form
Dental
HealtH spenDinG aCCount
If your plan provides a Health Spending Account, should any unpaid balance of this claim be reimbursed
Claim
treatment plan
under your account?
Yes
No
instruCtions
DireCt Deposit anD eleCtroniC Claim statement
Please mail your completed claim form and receipts to:
You will receive your claim payments faster with direct deposit and enjoy the convenience of seeing your
Co-operators Life Insurance Company
claim statements online.
Dental Claims
Sign up for direct deposit and electronic claim statements by calling our Client Service Centre at
1920 College Avenue
1-800-667-8164 or signing in to Benefits Now
.
TM
Regina, SK S4P 1C4
part 1 - Dentist
Last Name
Given Name
Specialty
I hereby assign my benefits payable
unique number
p
from this claim to the named dentist and
r
authorize payment directly to him/her.
o
p
Address
V
a
i
t
i
D
City
Province
Postal Code
e
e
____________________________________
r
n
Telephone Number:
Plan Member Signature
t
patient
I understand that the fees listed in this claim may not be covered by or may exceed my plan
Duplicate Form
iD number
benefits. I understand that I am financially responsible to my dentist for the entire treatment.
I acknowledge the total fee of $ _____________________ is accurate and has been charged
provider’s use only - For additional information, diagnosis, procedures or special considerations.
to me for services rendered. I authorize release of the information contained in this claim
form to my insuring company/plan administrator.
_____________________________________________
patient (parent/guardian) signature
Was this emergency treatment?
Yes
No If Yes, please provide additional details.
_____________________________________________
Office Verification:
Radiographs (large/small)
Models
Photographs
Written Diagnostic Report
attaChments:
Dentist/Denturist Signature
DATe OF SeRVICe
PROCeDuRe CODe
TOOTH CODe
TOOTH SuRFACeS
PROFeSSIONAL Fee
LABORATORY CHARGe
TOTAL CHARGeS
(MMM/DD/YYYY)
This is an accurate statement of services performed and the total fee due and payable, e & Oe.
total fee submitted $
part 2 - plan member information
Group ________________
Account __________________
Certificate ______________________ Plan Sponsor/employer ________________________________
Plan Member ____________________________________ ______
_______________________________________ Date of Birth __________________________
First Name
Initial
Last Name
MMM/DD/YYYY
Address ______________________________________________ __________________________________ _________________________ ____________________
Street
City
Province
Postal Code
part 3 - patient information
1. Relationship to Plan Member _____________________________________________________________________________
Date of Birth ___________________
MMM/DD/YYYY
If child, indicate
Student
Handicapped
If a student, please ensure the annual Student eligibility Form has been completed and submitted to our office by August 15 of each year.
2. Co-ordination of Benefits
If this expense has been considered by another carrier, you must attach the original explanation of benefits from that plan along with copies of the receipts.
Are you or your dependents covered by another plan?
Yes
No If yes, provide the following:
Spouse Date of Birth ______ __________________
Insurance Company Name/Source: ______________________________ Policy: ____________________
Day
Month
If your spouse’s benefit plan is with Co-operators Life Insurance Company, do you want us to process the claim through both benefit plans?
Yes
No
Spouse’s Policy _________________________________________________________________________
Certificate ___________________________________
3. Is any treatment related to an accident?
Yes
No
If yes, a Supplementary Dental Accident Report form will be sent directly to your dental office for completion.
4. If denture, crown or bridge, is this initial placement?
Yes
No
If no, give date of prior placement and reason ______________________________________________________________________________________________
(
)
see reverse
5. Is any treatment related to orthodontics?
Yes
No
Co-operators Life insuranCe Company
LC231 (09/11)
1920 CoLLege avenue regina sK
s4p 1C4
pg 1 of 2
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Parent category: Medical