Form F54-288a - Dental Care Claim Form Page 2
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21. If expenses are incurred for a dependent, specify:
Last name
First name
_____________________________________________________________________
___________________________________________________________________
Y
M
D
Relationship to member
Date of birth
_____________________________________________________
18
Children 18 and over:
Handicapped
Full-time student
Name of school __________________________________________
2. If the claim is the result of an accident, specify:
Work
Motor vehicle
Other
and complete the “Dental Care in Case of an Accident” form (F54-267A)
3. Is any treatment planned for orthodontic purposes?
Yes
No
4. For a denture, crown or bridge, is this an initial placement?
Yes
No
IF YES, please submit pre-treatment x-rays.
Y
M
D
IF NO, specify date of prior placement
and the necessity for replacement:
________________________________________
____________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
5. For a fixed bridge, have you or do you currently wear a partial denture?
Yes
No
Y
M
D
IF YES, specify date of last placement
and the necessity for replacement:
________________________________________
____________________________________________________________________________________________________________________________________________________________________
MEMBER CONFIRMATION/AUTHORIZATION
I HEREBY CONFIRM that the information contained in this claim form is true and complete to the best of my knowledge.
If this claim is being made on behalf of my spouse and or/dependent children, I CONFIRM that I am AUTHORIZED to disclose information
about them with respect to this claim.
On behalf of myself and my dependents:
(1) I consent to the RELEASE of the information contained in this claim form to Industrial Alliance Insurance and Financial Services
Inc., its employees, agents, reinsurers and service providers for the purposes of underwriting, administration and processing of the
claim; and
(2) I AUTHORIZE any healthcare provider or professional, medical organization, insurance or reinsurance company, workers’ compen-
sation board, the policyholder, my employer, as well as any other person, private or public organization or institution to disclose to
Industrial Alliance, its employees, agents and service providers any information regarding the treatment charges incurred which they
may need in the assessment of the claim.
(3) I UNDERSTAND AND AUTHORIZE that in the event there is reasonable suspicion of or any evidence of fraud or abuse regarding the
claim, Industrial Alliance will have the right to use and exchange any information related to the claim with any relevant regulatory,
investigative or government body, any healthcare provider or professional medical organization, insurance company or reinsurer, the
policyholder, my employer or any other party as provided by law for the purpose of investigating any such fraud or abuse.
I UNDERSTAND that personal information may be subject to disclosure to those authorized under the applicable laws within or
outside of Canada.
I AUTHORIZE the use of my Social Insurance Number as an identification number where it is required for the administration of the group policy.
I AGREE that a photocopy of this Confirmation/Authorization shall be as valid as the original.
Y
M
D
X
Member’s signature
Date
________________________________________________________________________________________________
Address
Postal code
_________________________________________________________________________________________________________________
Tel. home
Tel. work
Ext.
iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.
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