AVIVA LTD Dental Claim Form PDF Details

Navigating through the process of dental claims can seem daunting, yet with Aviva Ltd's structured and comprehensive Dental Claim Form, the process is streamlined for both the employee and the dentist involved. Designed with clarity in mind, this form is divided into two major sections: the first to be completed by the employee and the second by the dentist providing the treatment. Employees are obligated to initially cover the dental expenses and then attach the receipt to this form as a part of their reimbursement request from Aviva Ltd. Key personal and employment details including the policy or card number, and relationship to the patient if the claimant is not the patient themselves, are required in Section I. Additionally, for ease of transaction, employees are advised to update their bank account details if there have been any changes, facilitating direct credit reimbursements. Section II caters to the dental professionals, demanding specific information about the treatment provided, including the date, type of treatment dispensed, and costs incurred. The form also meticulously outlines different types of dental treatments and codes for easy identification and billing purposes. A signature from both the employee and the dentist at the end certifies the information provided, ensuring a smooth claim process. Lastly, a note underscores the importance of submitting the completed claim form alongside the treatment receipt to Aviva Ltd for processing, highlighting the company's commitment to expedite the reimbursement directly to the employee’s bank account, accompanied by a payment advice for complete transparency.

QuestionAnswer
Form NameAVIVA LTD Dental Claim Form
Form Length2 pages
Fillable?Yes
Fillable fields100
Avg. time to fill out20 min 34 sec
Other namesaviva claim form pdf, aviva defer claim form, singapore aviva form online, aviva claim form

Form Preview Example

AVIVA LTD

DENTAL CLAIM FORM

(Patient is required to pay the dentist and attached receipt to seek reimbursement from Aviva Ltd)

SECTION I – TO BE COMPLETED BY THE EMPLOYEE

Name of Company

 

 

 

Policy/Card Number

 

 

 

 

 

 

Commencement of employment (dd/mm/yyyy)

Market unit/Dept

 

Daytime Contact No. (Mobile/Pager/Tel) *

 

 

 

 

 

 

Name of Patient

 

NRIC/BC/FIN No. of Patient

 

Sex

Date of Birth (dd/mm/yyyy)

 

 

 

 

M/F *

 

Name of Employee (If the patient is not the employee)

NRIC/FIN No. of Employee

 

Sex

Date of Birth (dd/mm/yyyy)

 

 

 

 

M/F *

 

Relationship

All reimbursements will be credited into your payroll’s bank account, please furnish your bank account number

 

only if there are recent changes to your bank account.

 

 

 

 

 

 

 

 

Wife/Husband/Son/Daughter *

Name of Bank

Branch Name / Branch Code

 

Account Number

 

 

 

 

 

EMPLOYEE’S SIGNATURE

 

Office email address (If available)

 

 

 

 

 

 

 

SECTION II – TO BE COMPLETED BY THE DENTIST

Date of Treatment

 

 

 

 

 

 

 

 

 

 

AVIVA

 

No. of

 

 

 

 

 

 

 

 

 

 

 

 

 

Office

 

Tooth

Amount

Others

Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF TREATMENT

 

 

 

Code

 

Treated

Incurred

(please indicate tooth number)

Incurred

1. Consultation / Examination

 

 

 

A01

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Scaling and Polishing

 

 

 

C01

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. X-rays

 

 

 

 

 

 

 

 

 

i) Periapical

 

 

 

B01

 

______

_______

 

 

ii) Bite Wing

 

 

 

B02

 

______

_______

 

 

iii) Occlusal Film

 

 

 

B03

 

______

_______

 

 

iv) Orthopantograph

 

 

 

B04

 

______

_______

 

 

4 Amalgam Restoration

 

 

 

 

 

 

 

 

 

i) 1 Surface

 

 

 

D01

 

______

_______

 

 

ii) 2 Surfaces

 

 

 

D02

 

______

_______

 

 

iii) 3 Surfaces

 

 

 

D03

 

______

_______

 

 

5. Tooth Colored Restoration

 

 

 

 

 

 

 

 

 

i) 1 Surface

 

 

 

E01

 

______

_______

 

 

ii) 2 Surfaces

 

 

 

E02

 

______

_______

 

 

iii) 3 Surfaces

 

 

 

E03

 

______

_______

 

 

6. Extraction of Tooth (inclusive of LA)

 

 

 

 

 

 

 

 

 

i) Anterior Tooth

 

 

 

F01

 

______

_______

 

 

ii) Posterior Tooth

 

 

 

F02

 

______

_______

 

 

7. Oral Surgery (inclusive of LA)

 

 

 

 

 

 

 

 

 

i) Incision & Drainage

 

 

 

G01

 

______

_______

 

 

ii) Excision of Hyper Plastic Tissue, Cyst

 

 

 

G02

 

______

_______

 

 

iii) Surgical Root Removal (per root)

 

 

 

G03

 

______

_______

 

 

iv) Surgical Removal of Wisdom Tooth (Soft Tissue)

G04

 

______

_______

 

 

v) Surgical Removal of Wisdom Tooth (Simple Bony Impaction)

G05

 

______

_______

 

 

8. Periodontal Treatment Root Planning

 

 

 

 

 

 

 

 

 

i) Per Tooth

 

 

 

H01

 

______

_______

 

 

ii) Per Quadrant

 

 

 

H02

 

______

_______

 

 

9. Pulp/Root Canal Treatment

 

 

 

 

 

 

 

 

 

i) Pulp Capping

 

 

 

I01

 

______

_______

 

 

ii) Root Canal - 1 Canal

 

 

 

I02

 

______

_______

 

 

2 Canals

 

 

 

I03

 

______

_______

 

 

10. Miscellaneous Treatment

 

 

 

 

 

 

 

 

 

i) Analgesics (Oral Only)

 

 

 

J01

 

 

_______

 

 

ii) Antibiotics (Oral Only)

 

 

 

J02

 

 

_______

 

 

iii) Administration of local Anesthesia

 

 

 

J03

 

 

_______

 

 

 

 

 

 

T O T A L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Dentist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DENTIST’S SIGNATURE & CLINIC’S STAMP

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

c:\denticcf.doc/15.12.2007

 

 

 

 

 

 

 

 

 

* Delete where applicable

AVIVA Ltd, Group Life & Health Claims

 

 

 

4 Shenton Way #01-01 SGX Centre 2 Singapore 068807

NOTE :-

1.Section I is to be completed by Employee.

2.Section II is to be completed by DENTIST.

3.Employee to pay the dentist after treatment and attached your receipt together with the completed claim form and submit to:-

Aviva Ltd

Group Life & Health Claims

4 Shenton Way

#01-01 SGX Centre 2

Singapore 068807

4.To expedite reimbursement, please provide your bank account for direct credit into your account. A payment advice will be sent upon credit to your bank account.

c:\denticcf.doc/15.12.2007

 

* Delete where applicable

AVIVA Ltd, Group Life & Health Claims

 

4 Shenton Way #01-01 SGX Centre 2 Singapore 068807

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