Blue Cross Form 013 B PDF Details

Blue Cross Form 013 B was designed to provide a summary of an individual's current and past health coverage. The form is used by insurance providers, employers, and other organizations to determine eligibility for benefits and to verify previous coverage. The form is also used to calculate the amount of any potential refund or settlement. Navigating the complexities of Blue Cross Form 013 B can be difficult, but our team at ABC Healthcare is here to help. With over 10 years of experience in health insurance, we can guide you through every step of the process. Contact us today for more information!

QuestionAnswer
Form NameBlue Cross Form 013 B
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names

Form Preview Example

644 MAIN ST PO BOX 220 MONCTON NB E1C 8L3 INQUIRIES: 1-800-667-4511

7 SPECTACLE LAKE DR DARTMOUTH

185 THE WEST MALL SUITE 1200

PO BOX 2200 HALIFAX NS B3J 3C6

ETOBICOKE ON M9C 5P1

INQUIRIES: 1-800-667-4511

INQUIRIES: 1-800-355-9133

STANDARD DENTAL CLAIM FORM

CANADIAN LIFE

AND HEALTH INSURANCE

ASSOCIATION INC.

PART 1 DENTIST

P

 

 

A FIRST NAME

LAST NAME

T

ADDRESS

APT.

I

 

 

E

CITY

PROV.

N

 

 

TPOSTAL CODE

UNIQUE NO.

SPEC

PATIENT'S OFFICE ACCOUNT NO.

 

 

 

D

E

N

T

I

S

TPHONE NO.

I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM TO THE NAMED DENTIST AND AUTHORIZE PAYMENT DIRECTLY TO HIM/HER.

SIGNATURE OF SUBSCRIBER

FOR DENTIST'S USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES, OR SPECIAL CONSIDERATION.

DUPLICATE FORM

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 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 DENTIST.

SIGNATURE OF PATIENT (PARENT/GUARDIAN)

OFFICE VERIFICATION

DATE OF SERVICE

PROCEDURE CODE

INTL

TOOTH

 

DENTIST'S FEE

 

LABORATORY

 

TOTAL CHARGES

 

 

 

 

 

 

 

 

 

 

 

FOR CARRIER USE

DAY

MO.

YR.

 

 

 

 

 

TOOTH CODE

SURFACES

 

 

 

 

 

 

 

CHARGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALLOWED AMOUNT

INC

%

PATIENT'S SHARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHEQUE NO.

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEDUCTIBLE

 

PATIENT

PLAN PAYS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS IS AN ACCURATE STATEMENT OF SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIM NO.

 

 

 

 

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

TOTAL FEE SUBMITTED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS FOR CLAIM SUBMISSION

BEING A STANDARD FORM, THIS FORM CANNOT INCLUDE SPECIFIC INSTRUCTIONS ON WHERE IT SHOULD BE SENT, DEPENDING ON WHO IS THE CARRIER FOR YOUR PLAN. YOU CAN OBTAIN DETAILS FROM EITHER YOUR PLAN BOOKLET, YOUR CERTIFICATE OR FROM YOUR EMPLOYER.

IF YOUR PLAN REQUIRES SUBMISSION DIRECTLY TO THE CARRIER, PLEASE SEND THIS FORM WITH ONLY PARTS 1, 2 AND 3 COMPLETED TO THE CARRIER'S APPROPRIATE CLAIMS OFFICE.

IF YOUR PLAN REQUIRES SUBMISSION TO YOUR EMPLOYER, PLEASE DIRECT THIS FORM TO YOUR PERSONNEL OFFICE PLAN ADMINISTRATOR WHO WILL COMPLETE PART 4 AND FORWARD THE FORM TO THE CARRIER.

PART 2 - EMPLOYEE/PLAN MEMBER/SUBSCRIBER

1. POLICY NO.

 

 

2. YOUR NAME (PLEASE PRINT)

 

 

 

EMPLOYER

 

 

YOUR CERT. NO. OR S.I.N. OR I.D. NO.

 

 

 

 

NAME OF INSURING AGENCY OR PLAN

 

YOUR DATE OF BIRTH

 

 

 

 

DAY MO. YR.

 

 

 

 

PART 3 - PATIENT INFORMATION

1. RELATIONSHIP TO EMPLOYEE/PLAN MEMBER/SUBSCRIBER

DATE OF BIRTH

 

IF CHILD, INDICATE STUDENT HANDICAPPED

DAY MO.

YR.

 

IF STUDENT, INDICATE SCHOOL

PATIENT I.D. NO.

2. ARE ANY DENTAL BENEFITS OR SERVICES PROVIDED UNDER ANY OTHER GROUP

INSURANCE OR DENTAL PLAN, W.C.B. OR GOV'T PLAN? NO

YES

POLICY NO.

 

SPOUSE DATE OF BIRTH

 

 

 

 

 

DAY

MO. YR.

NAME OF OTHER INSURING AGENCY OR PLAN

SIGNATURE OF PATIENT (PARENT/GUARDIAN)

3.

IS ANY TREATMENT REQUIRED AS THE RESULT OF AN

 

 

 

ACCIDENT? IF YES, GIVE DATE AND DETAILS SEPARATELY.

NO

YES

4.

IF TREATMENT INCLUDES DENTURE, CROWN OR BRIDGE, IS THIS

NO

YES

 

AN INITIAL PLACEMENT? IF NO, GIVE DATE OF PRIOR PLACEMENT

 

 

 

AND REASON FOR REPLACEMENT.

 

 

 

 

 

 

 

 

 

 

 

 

DAY

MO.

YR.

 

 

5.

IS ANY TREATMENT REQUIRED FOR ORTHODONTIC PURPOSES?

NO

YES

 

 

 

 

 

 

6.I AUTHORIZE THE RELEASE OF ANY INFORMATION OR RECORDS REQUESTED IN RESPECT OF THIS CLAIM TO THE INSURER/PLAN ADMINISTRATOR AND CERTIFY THAT THE INFORMATION GIVEN IS TRUE, CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE. CLAIMING BENEFITS IMPLIES CONSENT TO BLUE CROSS PRIVACY PROTECTION PRACTICES.

DATE (DD/MM/YY)

PART 4 - POLICYHOLDER / EMPLOYER (FOR COMPLETION ONLY IF APPLICABLE. SEE ABOVE*)

1.DATE COVERAGE COMMENCED

2.DATE DEPENDENT COVERED

3.DATE TERMINATED

DAY

MO. YR.

4. CONTRACT HOLDER

DATE

DAY MO. YR.

AUTHORIZED SIGNATURE

(POSITION OR TITLE)

TM Registered Trade-mark of the Canadian Association of Blue Cross Plans.

ALL INFORMATION RECORDED ON THIS FORM IS CONFIDENTIAL.

FORM-013(B) 08/04

Blue Cross Form 013 B isn’t the one you’re looking for?

Related Documents