Fillable Dental Claim Form printable pdf download

DENTAL

CLAIM FORM

DO NOT WRITE IN THIS SPACE

Mail: PO Box 7000, Vancouver, BC V6B 4E1 | Drop it off: 4250 Canada Way, Burnaby, BC |

pac.bluecross.ca

Please enclose all supporting documentation, if necessary.

See page 2 for important information about preparing your dental claim.

PART 1 — PATIENT INFORMATION

PART 2 — PROVIDER INFORMATION

PART 3 — PLAN MEMBER

Patient’s first name

Unique number

Office number

Spec.

Patient’s office account number

Send payment to:

Plan member

Patient’s last name

Provider’s name

Provider — I hereby assign

my benefits payable from this

Street address

claim to the named dentist and

authorize payment directly to

City

Province

Postal code

City

him/her.

Additional information, diagnosis, procedures or special considerations

Province

Postal code

Phone number (10 digits)

Provider/authorized signature (or attach receipts showing payment for services)

Member’s signature

Date (mm-dd-yyyy)

PART 4 — CLAIM INFORMATION

SERVICE

PROCEDURE

INTL. TOOTH

TOOTH

DENTIST’S

LAB

TOTAL

SERVICE DESCRIPTION

DATE

CODE

SURFACES

FEE

CHARGE

CHARGES

(mm-dd-yyyy)

GRAND TOTAL

PART 5 — EMPLOYEE/PLAN MEMBER INFORMATION

Policy number

ID number

Employer’s name

Daytime phone number (10 digits)

Employee/Plan member’s first name

Employee/Plan member’s last name

Employee/Plan member’s birthdate (mm-dd-yyyy)

PART 6 — PATIENT INFORMATION

Patient’s birthdate (mm-dd-yyyy)

Relationship to Plan member:

Self

Spouse

Child

I understand that the fees listed in this claim may not be covered by or may exceed my plan benefits. I understand that I am financially responsible

to my dental provider 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 dental provider.

Patient’s signature (or parent/guardian)

Date (mm-dd-yyyy)

PART 7 — OTHER INSURANCE COVERAGE: Complete this section if these services are covered by any other dental plan

Name of person with other coverage

Birthdate of other coverage holder (mm-dd-yyyy)

Policy number

ID number

Employment status

Coverage type

Name of insuring company

Full-time

Part-time

Retiree

Single

Family

Effective date (mm-dd-yyyy)

Termination date (mm-dd-yyyy)

Is any treatment required as a result of an accident?

Yes

No (If yes, provide details separately.)

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0587.003—20-70-200 09/16 CUPE 1816

Dental Claim Form

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