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Form Dent Hsa E 11 10 is an annual return of organization (EO) tax form filed with the IRS by certain non-profit organizations. The Form is used to report the organization's income, expenses, and program service accomplishments for the year. The deadline to file Form Dent Hsa E 11 10 is May 15th each year. If you're not sure if your non-profit organization needs to file this form, or have any other questions related to Form Dent Hsa E 11 10, please contact an accountant or tax specialist.

The following are some specifics of form dent hsa e 11 10. It'll present you with the rough time you'll need to prepare the form plus some other details.

QuestionAnswer
Form NameForm Dent Hsa E 11 10
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names

Form Preview Example

Dental & Health Spending Account Claim Form

Approved by the Canadian Dental Association

1 | To be completed by Dentist

P

Last Name

 

Given Name

A

 

 

 

T

 

 

 

Address

 

Apt.

I

 

 

 

E

 

 

 

City

Prov.

Postal Code

N

 

 

 

T

 

 

 

Unique Number

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 m

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 in this claim form to my insuring company / plan administrator.

Signature of Patient (Parent/Guardian)

Office Verification/Dentist’s Signature

Date of Service

Day Month Year

Procedure

Code

Intl

Tooth

Code

Tooth

Surfaces

Dentist’s

Fee

Laboratory

Charge

Total Charges

For Plan Administrator Use Only

This is an accurate statement of services performed and the total fee due and payable E & OE

TOTAL FEE SUBMITTED

2 | Information about you – be sure to fully complete this section

Contract number

Member ID number

Your plan sponsor/employer

Preferred language of correspondence

m English m French

Your last name

First name

 

m Male

Date of birth (yyyy-mm-dd)

Daytime phone number

 

 

 

 

m Female

 

 

 

 

 

 

 

 

 

 

Your address (street number and name)

 

Apartment or suite

City

 

 

Province

Postal code

 

 

 

 

 

 

 

 

 

 

 

3 | Spouse and children covered by this claim – complete this section if claim is for spouse or child

Spouse’s last name

Child’s name

First name

 

 

 

Date of birth (yyyy-mm-dd)

m Male

 

 

 

 

 

m Female

Relationship to you

 

 

 

 

Date of birth (yyyy-mm-dd)

Complete for overage dependents (refer to benefit information

m Son m Daughter

for age limits)

m Disabled

m Full-time student

 

 

 

 

 

 

 

 

 

 

4| Co-ordination of benefits – complete this section if your spouse and/or children has coverage under any other dental plan or contract

Is your spouse or are your children covered for any of these expenses under any other dental plan or contract? m No m Yes

If yes,: • You must submit a claim for your spouse to his/her plan first.

You must submit a claim for your child first under the plan of the parent with the earliest birthday (month and day) in the calendar year. If your spouse’s plan is also with us, complete the following:

Contract number

Member ID number

Spouse’s date of birth (yyyy-mm-dd)

– –

Do you want us to co-ordinate benefits (process both claims)?

m No m Yes

If yes, spouse’s signature

Date (yyyy-mm-dd)

 

X

5| Health Spending Account – complete this section if you are covered with a Health Spending Account

If you’re covered under more than one benefits plan, you should consider submitting your claim to the other plan(s) before using your HSA. If you are using your HSA to claim for the unpaid amount previously submitted to this or another plan, attach the claim statement you received and a copy of the

receipts. Please select one of the following:

 

m You don’t want to use your HSA for this claim

m You want us to assess this claim under your HSA only.

mYou want us to assess this claim under your Extended Health Care benefit first and then assess any unpaid balance under your HSA.

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6 | Details of claim

If the cost of your treatment will exceed the pre-determination limit in your benefit plan, you should send an estimate to Sun Life Assurance Company of Canada. To determine if you will be reimbursed for the treatment, have your dentist complete a Pre-Treatment Form (available from your dentist).

1.

Are any expenses the result of an accident?

m No

m Yes

If yes, complete the following:

 

 

 

 

When did the accident occur? (yyyy-mm-dd)

Where did the accident occur?

 

How did the accident occur?

 

 

m Work

m Home

m Other

 

 

 

 

 

 

Are any expenses the result of a condition covered by a workers’ compensation program? m No

m Yes

 

 

 

 

 

 

 

2.

Is this treatment for orthodontic purposes?

m No

m Yes

 

Implants?

m No m Yes

3.

Crowns, Bridges, Dentures

Is this the initial placement? m No

m Yes

 

If No, date of prior placement (yyyy-mm-dd) Reason for replacement

– –

If Yes, date teeth were extracted (for denture or bridge)

(yyyy-mm-dd)

 

Please include the following to facilitate handling of your claim:

Pre-treatment x-rays (for crowns, bridges, veneers, inlays, onlays)

 

List of all missing teeth (for bridges only)

7 | Authorization and signature – you must complete this section

I certify that all goods and services being claimed have been received by me and/or my spouse or dependents, if applicable. I certify that the information in this form is true and complete and does not contain a claim for any expense previously paid for by this or any other plan.

If this claim is being made on behalf of my spouse and/or dependents, I am authorized to disclose information about them, for the purposes of underwriting, administration and adjudicating claims. I confirm that my spouse and/or dependents, if any, also authorize Sun Life Assurance Company of Canada (“Sun Life”) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing my group benefits plan.

I authorize Sun Life and its reinsurers to collect, use and disclose information about me, and if applicable, my spouse and/or dependents needed for underwriting, administration and adjudicating claims under this Plan to any other organization who has relevant information pertaining to this claim including health professionals, institutions, investigative agencies and insurers. I also understand that information pertaining to this claim may be reviewed in the event this Plan is audited.

In the event there is suspicion and/or evidence of fraud and/or Plan abuse concerning this claim, I acknowledge and agree that Sun Life may investigate and that information about me, my spouse and/or dependents pertaining to this claim may be used and disclosed to any relevant organization including regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purpose of investigation and prevention of fraud and/or Plan abuse.

If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable to me under my benefit plan(s), and the collection, use and disclosure of information about this claim to other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor for that purpose.

If I am making a claim under my Health Spending Account, I certify that these expenses qualify for reimbursement.

I also acknowledge that the persons for whom I am making a claim are eligible and include myself, my spouse and any dependents as defined under the Health Spending Account coverage. I understand that should any tax consequences arise from reimbursement of these expenses, I am responsible for payment of such taxes. I also understand that my plan sponsor may have access to a summary of the total amounts claimed by me under my Health Spending Account for the purposes of tax or administrative reporting.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of this Plan.

Any reference to Sun Life Assurance Company of Canada or the Plan Sponsor includes their respective agents and service providers.

Member’s signature

X

Respecting your privacy

Date (yyyy-mm-dd)

– –

Your privacy is important to us. We may leverage our strengths in our worldwide operations and in our negotiated relationships with third-party providers to help us service some of our customers. In some instances our employees, service providers, agents, reinsurers and any of their service providers, may be located in jurisdictions outside Canada, and your personal information may be subject to the laws of those foreign jurisdictions.

To find out about our Privacy Policy, visit our website at www.sunlife.ca, or to obtain information about our privacy practices, send a written request by email to privacyofficer@sunlife.com, or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto, ON M5V 3C5.

Questions? Please visit www.sunlife.ca or call our toll-free number 1-800-361-6212 Monday - Friday, 8 a.m. - 8 p.m. ET

Mailing instructions – keep a copy of your claim form and receipts for your records

Mail your completed

Sun Life Assurance Company

Sun Life Assurance Company

form to the claims

of Canada

of Canada

office nearest you.

PO Box 11658 Stn CV

PO Box 2010 Stn Waterloo

 

Montreal QC H3C 6C1

Waterloo ON N2J 0A6

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