Canada Dental Form – Fill Out and Use This PDF

The Canada Dental form, formally known as the Standard Dental Canadian Life and Health Claim Form, is a comprehensive document designed for dental insurance claims within Canada. It streamlines the process for patients to assign benefits directly to their dentists and to authorize the release of necessary information to insurance companies or plan administrators. For those looking to submit a dental claim, completing this form accurately is essential; click the button below to get started.

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Canada Dental Form PDF Details

Navigating the complexities of dental insurance claims in Canada can be simplified using the Standard Dental Canadian Life and Health Claim Form. This comprehensive document, created by the Canadian Life and Health Insurance Association Inc., serves as a key tool for patients to communicate with their insurance carriers regarding dental services. The form encompasses multiple sections designed to capture essential details about the patient, the dentist, the dental procedure performed, and the financial aspects of the claim. From assigning benefits directly to the dentist to providing specific information on the procedure codes, tooth numbers, and fees charged, the form facilitates a streamlined claim submission process. It also addresses other crucial aspects, like the possibility of other insurance coverage, accident-related treatments, and treatments for orthodontic purposes. Moreover, it includes a declaration by the patient or plan member, confirming the accuracy of information provided and authorizing the release of relevant records to the insurer or plan administrator. The versatility of the form is evident in its design to accommodate direct submission to the insurance carrier or through an employer's personnel office, making it a pivotal resource for managing dental care expenses in Canada.

Question	Answer
Form Name	Canada Dental Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	standard dental claim form canada, canada dental claim form, standard dental claim form, dental form canada

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STANDARD DENTAL

CANADIAN LIFE AND HEALTH

CLAIM FORM

INSURANCE ASSOCIATION INC.

UNIQUE NO.

SPEC.

PATIENTS OFFICE ACCOUNT NO.

PART 1 DENTIST

I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM

TO THE NAMED DENTIST AND AUTHORIZE PAYMENT TO

HIM/HER

______________________________________________________________

FIRST NAME

LAST NAME

______________________________________________________________

ADDRESS

APT.

______________________________________________________________

CITY

PROV.

POSTAL CODE

PHONE NO.

SIGNATURE OF SUBSCRIBER

FOR DENTIST USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES,OR SPECIAL CONSIDERATIONS.

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 ADMINISTRAT O R. 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

INTL.

TOOTH

DENTIST’S

LABORATORY

TOTAL

DAY

MO.

YR.

CODE

TOOTH CODE

SURFACES

FEE

CHARGE

CHARGES

THIS IS AN ACCURATE STATEMENT OF SERVICES PERFORMED	TOTAL FEE SUBMITTED
AND THE TOTAL FEE DUE AND PAYABLE, E & OE.

INSTRUCTIONS FOR CLAIM SUBMISSION

FOR CARRIER USE

ALLOWED AMOUNT	INC	%	PATIENT’S SHARE

CHEQUE NO.		DATE

DEDUCTIBLE	PATIENT PAYS		PLAN PAYS

CLAIM NO.

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 YOU 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. GROUP POLICY/PLAN NO._____________________________DIVISION/SECTION 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	MONTH	YEAR

PART 3 - PATIENT INFORMATION

1. PATIENT: RELATIONSHIP TO EMPLOYEE/

PLAN MEMBER/SUBSCRIBER _________________________________________________________

DATE OF BIRTH _________________________ IF CHILD INDICATE: ❏STUDENT ❏HANDICAPPED

DAY	MONTH	YEAR
IF STUDENT, INDICATE SCHOOL ________________________________________________________
PATIENT I.D. NO. ____________________________________________________________________
2. ARE ANY DENTAL BENEFITS OR SERVICES PROVIDED UNDER ANY OTHER GROUP INSURACE OR DENTAL
PLAN, W.C.B. OR GOV’T PLAN?	❏ NO	❏ YES

POLICY NO. ____________________________ SPOUSE DATE OF BIRTH ______________________________

NAME OF OTHER INSURING AGENCY OR PLAN ___________________________________________________

3.	IS ANY TREATMENT REQUIRED AS THE RESULT OF AN ACCIDENT?	❏ NO	❏ YES
	IF YES, GIVE DATE AND DETAILS SEPERATELY.
4.	IF DENTURE, CROWN OR BRIDGE, IS THIS INITIAL PLACEMENT?	❏ NO	❏ YES
	GIVE DATE OF PRIOR PLACEMENT AND REASON FOR REPLACEMENT.	❏ NO	❏ YES
	GIVE DATE OF PRIOR PLACEMENT AND REASON FOR REPLACEMENT.
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.

DATE _________________________

DAY MONTH YEAR

___________________________________________________

SIGNATURE OF EMPLOYEE/PLAN MEMBER/SUBSCRIBER

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

DAY

1.DATE COVERAGE COMMENCED

2.DATE DEPENDENT COVERED

3.DATE TERMINATED

MONTH

YEAR			DATE

	4. CONTRACT HOLDER				AUTHORIZED SIGNATURE
		DAY	MONTH	YEAR

					(POSITION OR TITLE)

ALL INFORMATION RECORDED ON THIS FORM IS CONFIDENTIAL

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Tips to fill out fillable dental claim form part 1

2. When the last section is completed, you have to put in the required specifics in THIS IS AN ACCURATE STATEMENT OF, TOTAL FEE SUBMITTED, CHEQUE NO, DATE, DEDUCTIBLE, PATIENT PAYS, PLAN PAYS, CLAIM NO, INSTRUCTIONS FOR CLAIM SUBMISSION, PART EMPLOYEEPLAN, GROUP POLICYPLAN, YOUR NAME PLEASE PRINT , EMPLOYER , YOUR CERT NO OR SIN OR ID NO , and NAME OF INSURING AGENCY OR PLAN allowing you to go further.

INSTRUCTIONS FOR CLAIM SUBMISSION, PLAN PAYS, and PATIENT PAYS in fillable dental claim form

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3. Completing DATE COVERAGE COMMENCED, DATE DEPENDENT COVERED, DATE TERMINATED, DAY MONTH YEAR, DATE, CONTRACT HOLDER, DAY MONTH YEAR, COPYRIGHT , ALL INFORMATION RECORDED ON THIS, AUTHORIZED SIGNATURE, and POSITION OR TITLE is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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Canada Dental Form – Fill Out and Use This PDF

Canada Dental Form PDF Details

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