P. O. BOX 1608 Windsor, Ontario N9A 7G1
Attn: Dental Department or Customer Service Centre 1-888-711-1119
DENTAL CLAIM FORM
I hereby assign my benefits payable from this
claim to the named provider and authorized
payment directly to him/her
PART 1 - PROVIDER
Given NamePatient Last Name
P
.
A
Apt.Address
T
I
E
Postal CodeProv.City
N
T
Patient's Office Account No.SpecUnique No.
Phone No
P
Signature of Plan Member
R
O
V
I
D
E
R
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 provider for the entire treatment. I acknowledge that the total fee of $ __________
For provider's use only - for additional information, diagnosis,
procedures, or special consideration.
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..
Duplicate Form
I also authorize the communication of information related to the coverage of services described in this form to the named
provider.
Signature of Patient (Parent/Guardian)
Office Verification
CodeAllowed AmountTotal Charges
Laboratory Charges
Provider's Fee
Tooth SurfacesInt'l Tooth Code
Procedure Code
Date of Service
DAY MO YR.
TOTAL FEE SUBMITTED
This is an accurate statement of services performed and
the total fee due and payable, E & OE.
INSTRUCTIONS FOR CLAIM SUBMISSION:
Please carefully fill in all pertinent areas and sign the completed form. (Refer to Green Shield Identification Card for correct patient information). Incomplete or incorrect claim forms
will be returned or rejected and will result in a delay in reimbursment.
All claims must be submitted within 12 months of the date of service (unless otherwise
stated in your benefit plan documentation).
PART 2 - EMPLOYEE/PLAN MEMBER
Plan Member's Date of BirthPlan Member's Identification NumberPlan Member's Name (Please Print)
DayMoYr
-00
Given NamesLast Name
PART 3 - PATIENT INFORMATION
Patient's Date of Birth
Patient's Identification NumberPatient's Name (Please print)
DayMoYr
--
Given NamesLast Name
3. Is any treatment required as the result of an accident? if Yes, give
date and details separately.
1. Patient: Relationship to Plan Member
YesNo
4. If denture, crown or bridge, is this initial placement? Give date of
prior placement and reason for replacement.
YesNo
HandicappedStudentIf child, indicate:
5. Is any treatment required for orthodontic purposes?If student, indicate school
YesNo
I authorize the release of any information or records required
in respect of this claim to insurer/plan administrator and
YesNo
2.Are any dental benefits or services provided under any other group insurance
or dental plan, W.S.I.B. or Government plan?
certify that the information given is true, correct and
complete to the best of my knowledge.
If Yes, Policy No. Spouse Date of Birth
Date
Name of other insuring Agency or Plan
Ye arMonthDay
Signature of Plan Member
All information recorded on this form is confidential.
By signing this claim form and/or submitting actual receipts, I agree that the information provided on this form is complete and accurate. I understand that the information provided by me to Green Shield Canada about myself
and my dependents, will be used by Green Shield Canada for claims adjudication and any other services necessary in the administration of our benefits which may include the exchange of information with other parties to administer
this benefit claim. I am authorized by my spouse and/or dependents to disclose and receive information about them that is used for these purposes. I understand that this information may be seen by the cardholder.
DE (Rev. 201-)
