Fillable Dental Benefits Claim Form printable pdf download

DENTAL BENEFITS CLAIM FORM

BENEFIT PLAN ADMINISTERED BY:

BENEFIT PLAN ADMINISTRATORS LIMITED

Canadian Dental

Canadian Life and Health

Association

Insurance Association Inc.

I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS

PART 1 DENTIST

UNIQUE NO.

SPEC.

PATIENT'S OFFICE ACCOUNT NO.

CLAIM TO THE NAMED DENTIST AND AUTHORIZE PAYMENT

DIRECTLY TO HIM/HER.

LAST NAME

GIVEN NAME

________________________________________________

. T

________________________________________________

__________________________________________________

PHONE NO.

CITY

PROV.

POSTAL CODE

SIGNATURE OF SUBSCRIBER

FOR DENTIST’S USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES

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 DENTIST FOR THE ENTIRE

OR SPECIAL CONSIDERATION

TREATMENT.

S I

CHARGED TO ME FOR SERVICES RENDERED.

I AUTHORIZE RELEASE OF THE INFORMATION CONTAINED IN THIS CLAIM FORM TO MY INSURING COMPANY/

PLAN ADMINISTRATOR.

________________________________________

SIGNATURE OF PATIENT (PARENT/GUARDIAN)

OFFICE VERIFICATION

DUPLICATE FORM

INTL.

INSTRUCTIONS

DATE OF SERVICE

PROCEDURE

TOOTH

DENTIST’S

LABORATORY

TOOTH

TOTAL CHARGES

DAY MO

CODE

SURFACES

FEE

CODE

CHARGE

IF CHARGES WILL BE $300 OR MORE, YOUR CLAIM SHOULD

BE SUBMITTED FOR PREDETERMINATION OF BENEFITS.

ROUTINE ORAL EXAMINATIONS, SCALING AND CLEANING,

FLUORIDE TREATMENTS, X-RAYS, BASIC RESTORATIONS

AND EMERGENCY TREATMENT MAY BE PERFORMED BY

YOUR DENTIST PRIOR TO SUBMITTING YOUR CLAIM FOR

PREDETERMINATION OF BENEFITS.

X-RAYS MAY BE REQUESTED TO BE SUBMITTED FOR

CROWNS OR BRIDGEWORK. X-RAYS WILL BE RETURNED

PROMPTLY TO YOUR DENTIST.

MAIL ALL CLAIM FORMS, PREDETERMINATIONS

AND X-RAYS TO:

BENEFIT PLAN ADMINISTRATORS LIMITED

2 - 1793 Dundas Street

London, Ontario N5W 3E6

THIS IS AN ACCURATE STATEMENT OF SERVICES PER-

TOTAL FEE SUBMITTED

FORMED AND THE TOTAL FEE DUE AND PAYABLE, E & OE.

PART 2 MEMBER'S STATEMENT

(Complete this part before taking the form to your dentist’s office.)

LOCAL NO.

1. MEMBER’S NAME: ___________________________________________

IDENTIFICATION NO. ______________________________________

__________________

(PLEASE PRINT)

ADDRESS:_____________________________________________________________________ TELEPHONE NUMBER: (________)____________________

___________

_____________________________________________________________________ DATE OF BIRTH:

_______________

_____________

____________

Day

Mo.

Yr.

IS THIS A CHANGE OF ADDRESS FROM YOUR LAST CLAIM SUBMISSION: YES (_) NO (_). IF YES, PLEASE ADVISE EFFECTIVE DATE OF CHANGE.

_____________

2. PATIENT: RELATIONSHIP TO MEMBER __________________

DATE OF BIRTH ________________

IF CHILD AGE 21 AND OVER, INDICATE

FULL-TIME STUDENT

HANDICAPPED

AUTHORIZATION: I certify that the above information is true, correct and

DATE ENROLLED ___________________ DATE COMPLETED ______________________________

complete. I authorize Benefit Plan Administrators Limited ("BPA") to collect

and use personal information about me and/or my eligible dependents to

process this claim and administer my benefit plan. I am aware BPA will keep

3. ARE ANY DENTAL BENEFITS OR SERVICES PROVIDED UNDER ANY OTHER

my personal information confidential and safeguarded.

GROUP INSURANCE, GOV’T. AGENCY OR DENTAL PLAN?

YES

POLICY NUMBER ________________________________

I am aware that BPA will only release personal information to my eligible

dependents specific to their benefit entitlements. I understand that my personal

NAME OF INSURING AGENCY _________________________________________________________

information (and the personal information of my eligible dependents) may only

IF CLAIMS FOR A DEPENDENT CHILD, PLEASE INDICATE SPOUSE’S DATE OF BIRTH __________

be shared with health care practitioners, medical facilities, providers of health

care/dental services or benefits administration services, provincial health

4. IS ANY TREATMENT REQUIRED AS THE RESULT OF AN ACCIDENT?

YES

insurance plans, insurance carriers, government agencies, and auditing or

independent investigative organizations in order to verify eligibility for my

IF YES, GIVE DATE AND DETAILS OF ACCIDENT

benefit entitlements.

___________________________________________________________________________________

I understand that my social insurance number will be kept in strictest

___________________________________________________________________________________

confidence and will only be used for income tax reporting purposes and to

match my information with the correct member file. I consent to the collection,

5. IF DENTURE, CROWN OR BRIDGE, IS THIS INITIAL PLACEMENT?

YES

use and disclosure of personal information as stated above.

IF INITIAL PLACEMENT ADVISE DATE TEETH WERE EXTRACTED __________________________

AND ALL OTHER MISSING TEETH IN ARCH _____________________________________________

_________________________________________________________________________

MEMBER’S SIGNATURE

IF REPLACEMENT GIVE DATE

OF PRIOR PLACEMENT AND REASON FOR REPLACEMENT

___________________________________________________________________________________

DATE _____________________/_____________________/________________________

___________________________________________________________________________________

6. IS YOUR DEPENDENT EMPLOYED?

YES

IS YOUR DEPENDENT ATTENDING SCHOOL?

YES

IF SO, GIVE NAME OF EMPLOYER OR SCHOOL

YOUR CLAIM CANNOT BE PROCESSED UNLESS ALL QUESTIONS ARE ANSWERED IN FULL

ALL INFORMATION RECORDED ON THIS FORM IS CONFIDENTIAL

POSSESSION OF THIS CLAIM FORM DOES NOT CONSTITUTE ELIGIBILITY FOR BENEFITS

Dental Benefits Claim Form

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