Canada Dental Form PDF Details

If you're a Canadian resident and need to see a dentist, you'll need to fill out a dental form. This form is used to document your dental health and identify any problems or concerns. You can either download the form from the internet or get one from your dentist. The form covers everything from your oral history to your current dental status. Make sure you complete the form in full, and be honest about any problems or concerns you may have. Doing so will help ensure that you receive the best possible care.

QuestionAnswer
Form NameCanada Dental Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesstandard dental claim form canada, canada dental claim form, standard dental claim form, dental form canada

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

______________________________________________________________

 

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

FIRST NAME

 

LAST NAME

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

T

 

 

 

 

 

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

I

 

______________________________________________________________

 

T

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

ADDRESS

 

APT.

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

T

 

______________________________________________________________

 

T

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

 

 

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)

COPYRIGHT 09/03

ALL INFORMATION RECORDED ON THIS FORM IS CONFIDENTIAL

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Tips to fill out fillable dental claim form part 1

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

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