Form F54-288a - Dental Care Claim Form
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1
2CLAIM FORM
GROUP
INSURANCE
DENTAL CARE
According to your province of residence, please submit form to:
Print
Quebec
Ontario, Atlantic and Western Provinces
Group Health and Dental Claims
Group Health and Dental Claims
PO Box 800, Station Maison de la Poste
PO Box 4643, Station A
Montreal, Quebec H3B 3K5
Toronto, Ontario M5W 5E3
PART 1: DENTIST’S STATEMENT
Dentist (Last and first name/Address/Phone no.)
Patient (Last and first name)
I hereby assign my benefits payable from this claim
to the named dentist and authorize payment directly
__________________________________________________
to him/her.
_____________________________________________________________________
__________________________________________________
For dentist’s use only to provide additional information, diagnosis,
procedures, or special considerations:
__________________________________________________
__________________________________________
Signature of subscriber
I understand that I am responsible for the fees incurred independent of the claim and the
coverage I have. I acknowledge that the total fee of $
is accurate and
___________________
has been charged to me for services rendered.
Member’s signature
________________________________________________________________________
Duplicate
Predetermination
Verification (Dentist)
________________________________________________________________________
Treatment and services rendered to the patient
INT. TOOTH
TOOTH
DENTIST’S
LABORATORY
TOTAL
DATE OF SERVICE
PROCEDURE
FEES
CODE
CODE
SURFACES
CHARGES
CHARGES
Y
M
D
Excluding any possible errors or omissions, this is an accurate statement of services performed
Total fee submitted
and the total fee due and payable.
PART 2:
MEMBER’S STATEMENT
Policy no.
Policyholder’s name
__________________________________________________________________________________________________________
Member’s last name
First name
__________________________________________________________________
_____________________________________________________________
Y
M
D
Certificate no.
Date of birth
Sex:
M
F
Language:
E
F
COORDINATION OF BENEFITS
IMPORTANT NOTE:
• If one of your dependents is covered under another plan for dental care expenses, the expenses incurred by this dependent must first be submitted to the other
insurer. You may subsequently submit a claim for the balance, if applicable, under your plan.
• The expenses incurred by dependent children must be submitted to the plan of the parent whose birthday comes first during a calendar year.
Are you or your dependents covered by another group plan?
No
Yes Specify:
Name of insurance company
Policy no.
Coverage:
Individual
Family
__________________________________________________________
__________________
Y
M
D
Name of spouse or child
Date of birth
_____________________________________________________________________________________
PLEASE COMPLETE AND SIGN THE REVERSE SIDE OF THIS FORM.
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F54-288A(15-12)
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Parent category: Legal